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How come (most) health insurance does not cover spinal fusions?

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  • How come (most) health insurance does not cover spinal fusions?

    I just have a question.

    Does anyone know why this type of surgery not covered by most health insurance policy's/physicians. It just baffling to me that such an important surgery is not covered by most insurance policy's.

  • #2
    My insurance covered the surgery and never questioned me. The doctor's office worked out the details with the insurance, and had me pre-certified months before the surgery date.
    __________________________________________
    Debbe - 50 yrs old

    Milwalkee Brace 1976 - 79
    Told by Dr. my curve would never progress

    Surgery 10/15/08 in NYC by Dr. Michael Neuwirth
    Pre-Surgury Thorasic: 66 degrees
    Pre-Surgery Lumbar: 66 degrees

    Post-Surgery Thorasic: 34 degrees
    Post-Surgery Lumbar: 22 degrees

    Comment


    • #3
      Originally posted by debbei View Post
      My insurance covered the surgery and never questioned me. The doctor's office worked out the details with the insurance, and had me pre-certified months before the surgery date.
      I was cover at 100% w/a 250.00 in patient co-pay. No questions asked either. I have Blue Cross/Blue Shield-Empire Blue. A little pricy every pay check BUT well worth it when all is said & done. Who do you have,if you dont mind me asking?
      Lynn -30.... something
      DxD @ 8 yrs old: 10* curve-no brace-no nothin'!
      At age 26: Thorasic 48*/Lumbar 50*
      At age 34: Thorasic 58*/Lumbar 60*
      Posterior T5-L4 Fusion Jan 14th, 2009 w/Dr Tribus
      UW Madison, WI Hospital
      **AFTER: less than 10* Thorasic/15* Lumbar**

      Comment


      • #4
        Hi Lynne,

        I have Aetna. I had a $240 copay, then had to pay about $500 until I had reached my out of pocket max. Everything else was covered 100% for the rest of the year, thank goodness.
        __________________________________________
        Debbe - 50 yrs old

        Milwalkee Brace 1976 - 79
        Told by Dr. my curve would never progress

        Surgery 10/15/08 in NYC by Dr. Michael Neuwirth
        Pre-Surgury Thorasic: 66 degrees
        Pre-Surgery Lumbar: 66 degrees

        Post-Surgery Thorasic: 34 degrees
        Post-Surgery Lumbar: 22 degrees

        Comment


        • #5
          Originally posted by dontcallmecass View Post
          Does anyone know why this type of surgery not covered by most health insurance policy's/physicians. It just baffling to me that such an important surgery is not covered by most insurance policy's.
          Like LynnMarie and Debbe, my insurance covered the surgery with no questions.

          After I met my deductible, PHCS (my insurer) paid at 100%. They also reimbursed all my meds at 100% (all I had to do was fax them the pharmacy receipt). I think I met my deductible by the 2nd week of January - and the rest of 2008 was completely covered.

          Not that it matters, but I elected my company's HDMP/HSA vs. the traditional PPO. Both options were through PHCS: The PPO would have covered the surgery as well, but the HDMP was a better choice for me.

          Can you elaborate on why you say "most" insurance policies won't cover it?

          Regards,
          Pam
          Last edited by txmarinemom; 02-13-2009, 07:50 PM. Reason: fat fingers (typo correction)
          Fusion is NOT the end of the world.
          AIDS Walk Houston 2008 5K @ 33 days post op!


          41, dx'd JIS & Boston braced @ 10
          Pre-op ±53°, Post-op < 20°
          Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


          VIEW MY X-RAYS
          EMAIL ME

          Comment


          • #6
            Originally posted by txmarinemom View Post
            Like LynnMarie and Debbe, my insurance covered the surgery with no questions.

            After I met my deductible, PHCS (my insurer) paid at 100%. They also reimbursed all my meds at 100% (all I had to do was fax them the pharmacy receipt). I think I met my deductible by the 2nd week of January - and the rest off 2008 was completely covered.

            Not that it matters, but I elected my company's HDMP/HSA vs. the traditional PPO. Both options were through PHCS: The PPO would have covered the surgery as well, but the HDMP was a better choice for me.

            Can you elaborate on why you say "most" insurance policies won't cover it?

            Regards,
            Pam
            I have Cigna.

            Every single doctor I have seen so far (four) have told me they do not cover this procedure.

            In fact, a friend of mine who has had 4 corrective fusions in total, also had the same problem. No one covered the surgery. In fact, I think she told me the surgeon fee alone for her last surgery was 100,000 and that insurance did not completely go through.

            she also has cigna though, I think.

            Comment


            • #7
              Insurance coverage

              My first surgeries were covered by BCBS Texas with no hesitation. Since 2006, I've been with Aetna and haven't had any problems whatsoever. I'm amazed Cigna does not cover - they have to be idiots. Best of luck to you.

              Christy
              Christy
              Plano, TX
              Surgical dates
              3/25/02 - fused T1-L3, T - 88 degrees
              L - 74 degrees
              7/8/04 - repaired 6 areas of non-union & fused L3-L4
              12/15/05 - fused L4-L5, L5-S1
              2/27/06 - corrected hardware failure
              3/5/06 - corrected hardware issue
              6/16/06 - replaced broken screw in pelvis
              3/9/07 - rear ended auto collision
              2/12/09 - totaled car - someone pulled out in front of me - Yikes!
              3/30/09 - Revision surgery, removed & replaced t12through S1

              Comment


              • #8
                Originally posted by dontcallmecass View Post
                I have Cigna.

                Every single doctor I have seen so far (four) have told me they do not cover this procedure.

                In fact, a friend of mine who has had 4 corrective fusions in total, also had the same problem. No one covered the surgery. In fact, I think she told me the surgeon fee alone for her last surgery was 100,000 and that insurance did not completely go through.

                she also has cigna though, I think.
                Look at this I found on the Cigna website. Perhaps your curve doesn't meet surgical criteria?

                And I find it very odd a surgeon would tell you whether your insurance will or won't cover surgery.

                Regards,
                Pam
                Fusion is NOT the end of the world.
                AIDS Walk Houston 2008 5K @ 33 days post op!


                41, dx'd JIS & Boston braced @ 10
                Pre-op ±53°, Post-op < 20°
                Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


                VIEW MY X-RAYS
                EMAIL ME

                Comment


                • #9
                  Originally posted by txmarinemom View Post
                  Look at this I found on the Cigna website. Perhaps your curve doesn't meet surgical criteria?

                  And I find it very odd a surgeon would tell you whether your insurance will or won't cover surgery.

                  Regards,
                  Pam
                  Thanks for the link, I was under the impression my curve was serious (51 degrees - when I last checked) but maybe according to cigna it is not.

                  There has only been one doctor who said he would work with me and he is not even part of my insurance policy (he said he would charge me what I would be charged if he had been covered though) ...this is getting aggravating. ;[

                  Comment


                  • #10
                    Originally posted by dontcallmecass View Post
                    Thanks for the link, I was under the impression my curve was serious (51 degrees - when I last checked) but maybe according to cigna it is not.
                    Criteria for surgery usually includes a curve with increasing pain (progressing or not), or a > 50° curve with documented progression.

                    A 51° curve (with the ±5° margin of error with the Cobb) could easily be anywhere in the range of 46°-56°. Maybe that, and if you haven't demonstrated progression, is factoring in.

                    Has CIGNA (not any surgeon's office) actually denied surgery in writing? If the pain is severe/increasing (or your curve is moving), I'd suggest you appeal their decision.

                    Also, be sure you're seeing scoliosis specialists - not just back surgeons/spinal orthos. You can find a list of qualified ones here.

                    Regards,
                    Pam
                    Fusion is NOT the end of the world.
                    AIDS Walk Houston 2008 5K @ 33 days post op!


                    41, dx'd JIS & Boston braced @ 10
                    Pre-op ±53°, Post-op < 20°
                    Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


                    VIEW MY X-RAYS
                    EMAIL ME

                    Comment


                    • #11
                      Originally posted by txmarinemom View Post
                      Criteria for surgery usually includes a curve with increasing pain (progressing or not), or a > 50° curve with documented progression.

                      A 51° curve (with the ±5° margin of error with the Cobb) could easily be anywhere in the range of 46°-56°. Maybe that, and if you haven't demonstrated progression, is factoring in.

                      Has CIGNA (not any surgeon's office) actually denied surgery in writing? If the pain is severe/increasing (or your curve is moving), I'd suggest you appeal their decision.

                      Also, be sure you're seeing scoliosis specialists - not just back surgeons/spinal orthos. You can find a list of qualified ones here.

                      Regards,
                      Pam
                      I don't have much pain (only when I stand for 4/5+ hours at a time) but my curve is progressing.
                      I have not had it measured in about a year and a half but it was 51 degrees at that point (and had progressed 15 degrees in the three years prior to the xray)

                      I lose my my health insurance soon as well, when I graduate college, which will prove to cause more aggravations.

                      I have been seeing scoliosis specialists actually, but I will take a look at the link provided. Thank you for all your help.
                      Last edited by dontcallmecass; 02-13-2009, 08:33 PM.

                      Comment


                      • #12
                        Originally posted by dontcallmecass View Post
                        I don't have much pain (only when I stand for 4/5+ hours at a time) but my curve is progressing.
                        I have not had it measured in about a year and a half but it was 51 degrees at that point (and had progressed 15 degrees in the three years prior to the xray)
                        5° progression a year (average) is significant, hon. While not a physical emergency at this point, it could well become one. *Especially* if you don't find a way to continue insurance coverage. The last thing you want is to be deemed uninsurable because of an excessive lapse in coverage.

                        Originally posted by dontcallmecass View Post
                        I lose my my health insurance soon as well, when I graduate college, which will prove to cause more aggravations.
                        Losing your coverage will be more than an aggravation. How long do you have until you graduate? Sorry to be nosey, but are you insured under your parents because you're a student? If so, is there any provision for continuation of coverage?

                        If neither applies, you really need to try to find an individual policy - and, no ... it will likely not be cheap. Surgery, however, is impossible for most without it.

                        The best indicator of future curve progression is past progression, and based on that, you need to plan ahead ... no matter how hard it hits your pocketbook.

                        Many insurance companies deny pre-existing conditions after a 63 day - at least that's the typical magic number in Texas - lapse in coverage for up to (in some cases) 10 years. If you truly are moving at 5° a year, you could be close to 100° in your early 30's.

                        I hope you fight this now while you still can. If you don't understand your policy - and your rights under it - please find someone who can help you and advocate for you. You really can't afford not to.

                        Best of luck. Keep us posted.

                        Best regards,
                        Pam
                        Fusion is NOT the end of the world.
                        AIDS Walk Houston 2008 5K @ 33 days post op!


                        41, dx'd JIS & Boston braced @ 10
                        Pre-op ±53°, Post-op < 20°
                        Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


                        VIEW MY X-RAYS
                        EMAIL ME

                        Comment


                        • #13
                          Originally posted by txmarinemom View Post
                          5° progression a year (average) is significant, hon. While not a physical emergency at this point, it could well become one. *Especially* if you don't find a way to continue insurance coverage. The last thing you want is to be deemed uninsurable because of an excessive lapse in coverage.



                          Losing your coverage will be more than an aggravation. How long do you have until you graduate? Sorry to be nosey, but are you insured under your parents because you're a student? If so, is there any provision for continuation of coverage?

                          If neither applies, you really need to try to find an individual policy - and, no ... it will likely not be cheap. Surgery, however, is impossible for most without it.

                          The best indicator of future curve progression is past progression, and based on that, you need to plan ahead ... no matter how hard it hits your pocketbook.

                          Many insurance companies deny pre-existing conditions after a 63 day - at least that's the typical magic number in Texas - lapse in coverage for up to (in some cases) 10 years. If you truly are moving at 5° a year, you could be close to 100° in your early 30's.

                          I hope you fight this now while you still can. If you don't understand your policy - and your rights under it - please find someone who can help you and advocate for you. You really can't afford not to.

                          Best of luck. Keep us posted.

                          Best regards,
                          Pam
                          Yes, I'm covered under my moms plan plan because I am a student. Coverage is good up to age 25 as long as you are a full time student. I am 22 now (will be 23 in October) but I only have three more semesters as a full time student.

                          When I graduate I can be put on a policy called Cobra? that her insurance plan offers to non-eligible children but its only for a certain number of months and is very pricey. It may just be better to look for a policy on my own.

                          Hopefully, I will find a solution to my problem soon.

                          Comment


                          • #14
                            A few things--

                            1) Doctors don't tell you what is covered vs. what is not--that is for the insurance to determine.

                            2) Pam is right about lapse in coverage. Do whatever you have to in order to make sure you stay covered. Look into the cobra rates. For us here in NJ, they are generally less $$ than individual rates that you can get on your own.

                            3) You do have some time with the 3 semesters. I'd recommend (like Pam suggested) that you see a scoliosis specialist. If you are progressing that fast, I would think they'd want to act quickly before you're too much worse.

                            Good luck.
                            __________________________________________
                            Debbe - 50 yrs old

                            Milwalkee Brace 1976 - 79
                            Told by Dr. my curve would never progress

                            Surgery 10/15/08 in NYC by Dr. Michael Neuwirth
                            Pre-Surgury Thorasic: 66 degrees
                            Pre-Surgery Lumbar: 66 degrees

                            Post-Surgery Thorasic: 34 degrees
                            Post-Surgery Lumbar: 22 degrees

                            Comment


                            • #15
                              Denied coverage

                              I have found that the most common reason for denied coverage is
                              1. a gap in your coverage. If you were uninsured 30 days in the past year, you may be denied benefits for a whole year after the fact for a preexisting condition.

                              2. the doctor you are seeing is out of network. If you have an HMO, they won't cover you at all. If you have a PPO, you may have coverage, but at a lower rate (eg 50% instead of 80%).

                              After graduation, take the COBRA for six months. Otherwise, you may find yourself in category 1. above. Hopefully, you will be gainfully employed within 6 months of graduation and will have your own insurance.

                              If you want to do the surgery before you graduate, you can do it over a summer semester and still be insured as a student. The 3 months off should give you adequate recovery time.

                              Also, I have to say I disagree with Debbei. You don't have to rush into this.

                              I hope this helps. If you or your parent calls Cigna, they should be able to tell you the reasons for denied medical coverage.

                              Best of luck.

                              p

                              Comment

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