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Old 07-06-2013, 12:19 PM   #1
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Denied surgery again!

OMG NO NO NO!!! Worker's Comp has denied my surgery AGAIN! There's a 20 day window to appeal the denial. I'm so glad I have a lawyer now. It was 4:55 yesterday when I opened the mail. I couldn't call my doctor's office or my lawyer. So now I have to wait through the weekend for any more information. Basically, Work Comp is saying that there isn't enough documented evidence that the procedure will make me better.

My doctor (a fellowship orthopedic spine surgeon) has requested an ALIF to fuse L3/4 and L4/5, and a laminectomy at whatever lumbar levels need it. My diagnosis is spondylolisthesis at L3/4 which is lateral and forward, and at L4/5 which is forward. The spondy is "progressive and significantly unstable." I am also diagnosed with stenosis, disc herniation, lumbar sprain/strain, and sciatica.

The tears fell freely after reading the denial. I simply can not imagine a life with this pain. I feel all out of strong and brave. I used it all up by deciding to finish the school year with my preschoolers when I was diagnosed in January. Now I won't be able to go back to my classroom until January, and if I don't get the surgery, I may not ever be able to go back. I don't just teach preschoolers, I am a Preschool Teacher. Capital letters because for the past 13 years, I have delighted in the fact that I've found my niche. I've just finished my 26th year teaching, and these past 13 have been the best.

I know I did more damage to my spondy by working the last 6 months. The pain is now defining me. I hate it. I hate it so much.

 
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Old 07-06-2013, 01:09 PM   #2
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Re: Denied surgery again!

Dear beedy bo, Im appalled, so sorry & the only thing i know to say is to tell you i went through workmens comp case years ago & it was like a nightmare that i could never wake up from! Due to the stress on my pregnancy at the time my husband deferred all calls, papers, etc to an attorney & it was relief from the stress anyway but the back pain & problems have continued to this day. I too found my niche with children & then in elementary school as a pupil services adjunct position & due to " incompatible with being alive pain" but i didnt know what i had then so i had to give up my long career working with neonates to 5th graders.Oh how i loved going to work & i too made my condition worse staying to work long after the dr told me to stop. It broke my heart but i got over it eventually. I have spondy, ddd, bulging discs, etc but cannot have surgery because of a condition called adhesive arachnoiditis & all i can do after 4 lumbar surgeries is to cover up the constant pain with long acting narcotics. I wanted surgery! Begged 3 different spine specialist NS's & no was the answer so i have to live this way. It took alot of getting used to but my point in all of this is i got over the loss & live a happy life with controlled pain most of the time.even without the surgery to fix me. The attorney will make them see that spondy & need for fusions is from previous injury & we will pray that all goes perfect so that you can return to "your" kids & your classroom but just in case it works out like me, you will be ok, everything will be ok. You will recover your strength, my mom says Every warrior has to lay down his sword for awhile, just awhile! Everything will work out but i know how disheartening it is when people wont care or cooperate, unnecessary waiting is frustrating beyond belief but we adapt & keep hoping, live one day at a time, see good drs & always do the best we can & its enough. Its enough to live happy as long as i still have hope! Im sorry, i understand but you will see it will be ok!

Last edited by gmak; 07-06-2013 at 01:21 PM. Reason: typos

 
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Beedy Bo (07-06-2013)
Old 07-06-2013, 01:23 PM   #3
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Re: Denied surgery again!

I'm so sorry for you. Having been through this myself, I know how helpless a feeling this is. There is an official-type document that spells out exactly what a patient must have wrong to qualify for a fusion. I don't know if workmen's comp uses this criteria, or not. I have never heard of a case where the spondylolisthesis is "progressive and unstable" that the patient didn't qualify for surgery. Instability is the main reason for doing a fusion.

Here are a couple thoughts for your attorney to find out:

Specifically what documented evidence do they need to allow your surgery?

Do you need to get more than one opinion from other spine surgeons stating that your spondy is unstable? (or whatever the criteria is for allowing surgery)

It may be that your doctor has not provided the specific information that they require. I think this is what happened to me and why my peer to peer was also denied.

 
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Beedy Bo (07-06-2013)
Old 07-06-2013, 10:19 PM   #4
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Re: Denied surgery again!

Oh I am so sorry to hear this. I just closed my WC claim but left medical open. Took a year to get my neck surgery. My best advice is to find the best WC attorney and fight it. Let a judge make the decision not WC.

 
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Beedy Bo (07-07-2013)
Old 07-09-2013, 08:33 AM   #5
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Re: Denied surgery again!

My lawyer says that a second denial is bad. Really bad. And due to the time constraints we have only this week to appeal. I broke down and cried in front of my 17 year old son yesterday. My coping mechanisms are not working. Not at rock bottom yet, but awfully close.

 
Old 07-09-2013, 09:07 AM   #6
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Re: Denied surgery again!

Beedy bo, Im so sorry that this is happening! Someone said that it could go to a judge somehow, is that a possibility? If wc wont cover it cant your regular insurance cover it? When i had to leave my elementary school clinic i did hit rock bottom & i know this sounds trite but its true there is nowhere to go but up & i got better, but it is not over! Have hope, we are praying for you! When will you know something, did the lawyer say?

Last edited by gmak; 07-09-2013 at 09:19 AM.

 
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Beedy Bo (07-10-2013)
Old 07-09-2013, 11:02 AM   #7
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Re: Denied surgery again!

Based on my experience...you first need to find out specifically why surgery was denied -- what criteria was used, what would have to be "wrong" for you to meet their criteria.

Then you need to see if your surgeon thinks you meet those standards....and if so, it would be really helpful to have another spine surgeon come to the same conclusion.

Do you know what your state's laws are regarding health insurance? I would assume your attorney does...but are you sure she/he does? In my state there are the appeals through the insurance carrier and then one can get an appeal through the state insurance board...but then that ruling is final. There is no where to go beyond that.

Based on everything I know about the criteria that many insurance carriers use, I can't figure out why there would be a problem unless somehow your spondy etc. has not been properly documented.

I would hope your attorney is on the phone with the appropriate people and is finding out specifically what criteria you did not meet. Unless workmen's comp completely changes things, I can't imagine why you were denied.

 
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Old 07-09-2013, 05:13 PM   #8
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Re: Denied surgery again!

Are all what you have listed approved WC injuries? They usually deny anything that's not approved injuries. I had ACDF C6/C7 and fell 3 weeks later, my attorney told me to have the doctor say it was from surgery and he wouldn't so now my C5 is herniated and not covered under WC. I always got determinations sent to me certified and 30 days started the day I get it. Each state is different though. I truly wish you the best and hope your attorney is the best in your state. When I think of WC, the only term that comes to mind is 'Nightmare'. Did they send you to IME Doctor? If so, your attorney should have given you a copy of their report.

 
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Old 07-09-2013, 05:21 PM   #9
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Re: Denied surgery again!

I just realized you are in CA which has similar WC rules to my state.

 
Old 07-10-2013, 06:29 AM   #10
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Re: Denied surgery again!

My lawyer is trying to get my doctor on the phone so they can be "on the same page" on terms of the appeal. She says unless she is able to speak with him today she will schedule an IMR (Independent Medical Review) asap. She says we only have one shot at this appeal and she's anxious that it be done correctly.

From what my dear husband and I can gather from the denial, Work Comp is claiming that fusion surgeries don't have a high enough success rate for them to authorize the request for treatment. They won't even authorize a new back brace, again claiming that there isn't enough evidence that shows a brace is helpful. I just don't get it.

My private insurance doesn't have to cover this, as it is well documented that my condition is from a work-related injury. I think that WC isn't buying my doctor's diagnosis of "Acquired Spondylolisthesis" and instead is focused on the degenerative aspect, in which case they believe it was not triggered by the original injury in 9/06. Just my guess.

Hopefully I will have more info by the end of today. In the meantime, my DH has promised me that he will make sure I get this surgery soon. Don't quite know how he's going to accomplish that, but the smart money's on him! He is my hero, and after 24 years of marriage, I know he always will be. <3

 
Old 07-11-2013, 07:00 AM   #11
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Re: Denied surgery again!

Heard from my lawyer yesterday - she spoke with the surgery scheduler who told her that the peer to peer has happened, they know what needs to be changed or added to the request for treatment and are well aware of the time constraints. The lawyer is encouraged by the progress and believes there will be a positive outcome! I don't want to get my hopes up in fear of a major disappointment, but this is the best news I've had in quite a while! Fingers crossed!

 
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Old 07-11-2013, 11:05 AM   #12
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Re: Denied surgery again!

You're really bring back bad memories for me. I didn't find out until 18 hours prior to leaving the house for the hospital that my surgery was not approved. Then for the next week, I remember sitting by the phone waiting for my surgeon's scheduler to call...I didn't want to be a pest but I wanted so badly to call to find out what was going on...I can remember that weekends were agony as I knew I wouldn't hear from anyone then.

I know how just having one little piece of information that is not acceptable to the insurance carrier can ruin the whole thing -- I can imagine that the "acquired spondylolisthesis" would do it!!

In my case, I had several MRIs including a positional MRI that was done in another state. All reports came to me through the mail. I was so hopeful that the positional MRI would clearly reveal what was causing my sciatic pain as nothing was obvious on the prone MRI. The MRI was sent to my surgeon but I was sent a copy of the radiology report...which I found out later had been done by some doctor that the company hired on a consulting basis. When I read through the report, I was shocked. One piece of information was impossibly wrong...meaning it said the disc at L4-L5 was bulging. It had been removed 18 months earlier and I had a PEEK cage instead. So rather than really following through on this with my surgeon, I mentioned it to him, and wrote a nasty letter to the MRI facility in another state, requesting that they correct the report, which I had come to believe was not even for my MRI, but was for another patient.

When I next saw my surgeon he showed me the films and we talked about it and he said they would take the report out of my file.

It was only after my surgery was denied and I had spent days putting together an appeal, gathering my medical records for a number of different specialists, MRI reports, etc. that it occurred to me, "what if that report was sent as proof why I needed surgery....?" Turns out it had been included in the material that was faxed to the insurance carrier.

I finally was scheduled to have my final review. One of their consulting doctors who was going to decide my case (he was a retired ortho who had specialized in joints), along with two people from the insurance company and one outside person, were going to meet, and I was "allowed" to come to present my case, although I was assured it wasn't necessary. So I spent a week trying to decide if I should go or not...spent a really restless weekend waiting for the date, after deciding I needed to be there even though it involved travelling to another state to get there....that Monday morning, the day before the meeting, as I was getting ready to leave the house, I got a call from the woman I had been dealing with at the company. Her words:
"the review has been cancelled." No details, nothing. She said she'd get back to me. The next day I got a call from the surgeon's scheduler telling me the meeting was cancelled because the hired retired ortho had received his packet (the one I'd assembled) in the mail, had opened it up and upon taking one look at the MRI had called headquarters and told them he would be voting in favor of me having surgery -- that there was no doubt in his mind that my spine was unstable and that I needed the surgery....so, it was scheduled for as soon as there was an opening.

I think I had a point when I began writing all this...but now I don't have a clue what it was. Maybe you'll be interested in hearing my story and know you aren't the only one...and mine wasn't even a workman's comp thing.

I think once they figure out just what the company needs in order to approve the surgery, they will decide in your favor!! I'll send some positive vibes your way.

 
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Old 07-11-2013, 11:16 AM   #13
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Re: Denied surgery again!

What a frustrating time that was for you! I totally understand. Wish I didn't, though!

This really is the first piece of good news I've had since the first denial. I'm going to call the scheduler today to see if she'll pencil me in for the first available date. I never would have imagined that I'd be so anxious to have major surgery!

Your help on this board is awesome. Your knowledge is always right on target, and your advice is spot on as well. Thank you!

 
Old 07-20-2013, 07:04 AM   #14
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Re: Denied surgery again!

What's going on?? Did they do the review?

 
Old 07-20-2013, 07:22 AM   #15
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Re: Denied surgery again!

Thanks for checking in with me! The appeal is now "under review" and we should know next week. The waiting is the pits! I'll keep you posted! Thanks again!

 
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