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  • Insurance appeal

    Hi Everyone, This forum has been such a blessing for my daughter and myself. She is 18 with a c-curve of approximately 60 degrees. We have recently decided it was time to start consulting with qualified spinal surgeons. We live in MA, so naturally we made an appointment with Dr. Emans. Wonderful reputation, wonderful facility except that our insurance co. has denied our request for her surgery to be done in Boston. Instead they gave us the name of a general surgeon who does do scoli sugery but is not a spinal specialist. We will not use him, period. Has anyone been denied by there ins. co.? We are appealing the ruling. Does anyone have any advise, key words, documentation we can add to the appeal? Thanks for any help you can provide. Jacquie

  • #2
    beachrose,
    Have you asked her primary care doctor to help you with the wording of your appeal? How can an insurance company even think that a general surgeon could do scoli surgery? You daughter needs to have a surgeon who does only scoli surgery and Boston should be the best choice for that. Where in MA do you live? You must have an HMO insurance. Insurance companies don't have a clue what is involved with scoliosis surgery. My insurance company couldn't or wouldn't tell me what surgeons do scoliosis surgery. I had to find my surgeon on my own. I was blessed.
    Good luck with your appeal. I'm sure you will succeed.
    Sally
    Diagnosed with severe lumbar scoliosis at age 65.
    Posterior Fusion L2-S1 on 12/4/2007. age 67
    Anterior Fusion L3-L4,L4-L5,L5-S1 on 12/19/2007
    Additional bone removed to decompress right side of L3-L4 & L4-L5 on 4/19/2010
    New England Baptist Hospital, Boston, MA
    Dr. Frank F. Rands735.photobucket.com/albums/ww360/butterflyfive/

    "In God We Trust" Happy moments, praise God. Difficult moments, seek God. Quiet moments, worship God. Painful moments, trust God. Every moment, thank God.

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    • #3
      I assume that you have an HMO policy, which essentially means that you give up your rights to choose your own medical professionals. I would personally wait until the next open enrollment, and opt for a more expensive PPO plan.
      Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
      ---------------------------------------------------------------------------------------------------------------------------------------------------
      Surgery 2/10/93 A/P fusion T4-L3
      Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

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      • #4
        hi Linda
        don't know what PPO's cost out on west coast...
        i am now paying $400 a month per person (for more than one person) for my HMO here on east coast!

        i don't know that many who can afford PPO...especially for families!

        jess

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        • #5
          I think I would ask the surgeon you want to use if his office can help you with your insurance appeal. They usually have staff trained to work with the insurance cos. and may be best able to explain why you need his expertise. Good luck!

          Evelyn
          age 48
          80* thoracolumbar; 40* thoracic
          Reduced to ~16* thoracolumbar; ~0* thoracic
          Surgery 3/14/12 with Dr. Lenke in St. Louis, T4 to S1 with pelvic fixation
          Broken rods 12/1/19; scheduled for revision fusion L1-L3-4 with Dr. Lenke 2/4/2020
          Not "confused" anymore, but don't know how to change my username.

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