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View Full Version : How come (most) health insurance does not cover spinal fusions?



dontcallmecass
02-13-2009, 03:19 PM
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.

debbei
02-13-2009, 04:39 PM
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.

LynnMarie74
02-13-2009, 05:12 PM
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?

debbei
02-13-2009, 05:27 PM
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.

txmarinemom
02-13-2009, 05:48 PM
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

dontcallmecass
02-13-2009, 07:35 PM
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.

csbaby
02-13-2009, 07:40 PM
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

txmarinemom
02-13-2009, 07:52 PM
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 (http://www.cigna.com/healthinfo/aa115911.html)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

dontcallmecass
02-13-2009, 08:09 PM
Look at this (http://www.cigna.com/healthinfo/aa115911.html)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. ;[

txmarinemom
02-13-2009, 08:27 PM
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 (http://www.srs.org/find).

Regards,
Pam

dontcallmecass
02-13-2009, 08:31 PM
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 (http://www.srs.org/find).

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.

txmarinemom
02-13-2009, 08:53 PM
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.


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

dontcallmecass
02-13-2009, 09:00 PM
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. :confused:

debbei
02-13-2009, 10:24 PM
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.

PNUTTRO
02-14-2009, 08:38 AM
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

dontcallmecass
02-14-2009, 10:52 AM
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


thanks for your advice. i do have in fact an hmo :mad:

and i wish i didn't have to rush into this, but i'll be graduating in the fall of 2010, so in order to be completely insured, i'll be needing to do it this summer.

pmsmom
02-14-2009, 01:01 PM
Thanks for this post.

My dh's carrier was just switched to Cigna. :(

Maybe it's in the way the doctor writes about the necessity for surgery?

Marian

asccbodypro
02-14-2009, 08:18 PM
Thank heavens for our Military coverage and we live near a great military hospital with a great surgeon! It's hard enough to face this surgery let alone having to worry about paying for it. Good luck!

Mom37
02-15-2009, 12:48 PM
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.

We went to both Shriner's and Scottish Rite for 2nd and third opinions and they did not charge anything. We did land up doing spinal fusion at Scottish Rite. They were excellent. We went to a second opinion due to rapid progression while braced. We chose Shriner's in Erie, PA as they also used the same Spincore brace as well as Boston hard brace the first doctor wanted us to use. They said no bracing would work and eventually in a couple to few years surgery would be needed. They paid for a hotel room for us in Erie. We went for a 3rd opinion at TSRHC (Scottish Rite). My insurance would cover (still lots of expense to us, but a fraction of the cost),but we were so impressed by Scottish Rite that we continued to go there. They went a step beyond the doctor I paid to see, and Shriners. They did an MRI and my daughter had a spinal cord issue. We were referred to one of the most experienced pediatric neurosurgeons and had surgery. Then had surgery at TSRHC when my daughter was able and needed surgery at no cost for all her orthopedic needs.

txmarinemom
02-16-2009, 11:48 AM
Mom37,

She's too old to receive care at Shriners or TSRH. They treat kids under 19 - although I have heard of cases where they treated patients over 19 who were previously treated there when they were age-eligible.

This isn't an option for her.

Regards,
Pam