How can I fight the insurance company and win?

Does anyone here have experience with medical insurance appeals and how to make it most likely that the appeal will be successful?

I think I've whined about this before, but the short recap is that:

My husband has had back pain for a decade subsequent to a horse-related injury (botched sliding stop that jammed his back) and increasing in severity over time. He's been under treatment by a spinal specialist for the last ~4 years, he had undergone drug therapy, physical therapy and several sets of epidural injections. His MRI results show significant disk deterioration, almost down to bone at L4-5 and significant at L5-S1. The last set of injections failed to provide relief. He cannot run, he now finds walking any distance painful, some days he has difficulty sitting at his desk for a full day. This is a man whose sport was ultra-distance running. He has become inactive and is gaining weight as a result.

His spinal doctor said it was time for surgery, went rounds with Anthem and got it approved. Then my husband got a new job and the timing with which the surgery could be scheduled (it's a 5 hour procedure involving an assistant surgeon to move the innards out of the way) was not ideal. He had to start the new job before the surgery, not after. We made arrangements for him to be able to take the necessary time off and even to keep the old insurance if it was necessary to keep the surgery date.

The surgeon's office asked for pre-certification on the new plan, thinking it would be no big deal under transition of care laws. However, CIGNA, the new insurer, denied it. A peer-to-peer was scheduled and it was denied a second time, at which point the surgical scheduler panicked and canceled the surgery before we could switch back to the old insurance.

The surgeon's office said that the doctor who participated in the peer to peer appeared to have his mind made up in advance. Today I spoke with a supervisor in the transition of care area and she was looking at Bill's file. She was under the impression that the peer-to-peer had not occurred because the doctor holding it made no notes except something about it being a waste of time.

CIGNA's written policy covers a single junction fusion in the case of degenerative disc disease such as my husbands but labels fusion in the case of multi-level degenerative disc disease as "unproven" and the denial appears to be on the grounds that 1 is good, but 2 is out of the question.

On paper, Anthem's policies seem even more restrictive, but they caved at the peer-to-peer level. Their policies do not appear as cut and dried, however. At least I could not find the relevant document that gave an overview of policy, just individual very specific aspects of fusion procedures.

I think given the apparent complete non-participation of the first M.D. that an appeal may be successful. The supervisor with whom I spoke seemed quite helpful and gave me her personal FAX number to send a copy of the appeal so she could move it through internal channels as well.

Now I want to put together a bulletproof case. If anyone has relevant experience, please let me know!

I wish I could help, but have no experience with fighting the insurance company.
I do however, have lots of surgury experience. Having had spinal fusiion 4 level lumbar and two level cervical. I pray your hubby has as great a surgeon as I had. He will do much better after the surgery. Though I was promised that the pain would never be gone, I still am much better than before surgery. Mine was in 95 and 96 so it has been awhile.

Best wishes to you and hubby.

wish i could help Deb...good luck


dusty

good luck with that. short of getting an attorney and ultimately seeking a writ of mandate, I don't know how to "win" against insurance.

In 2006 I broke my arm, paid my deductible, had surgery in October, insurance waited until january of the next year before denying the claim (even though it was preapproved), told me i had to pay the annual deductible again as it's a calendar year. They won't give you their internal policy manual. They make you spin around in circles.

Remember, insurance companies are for-profit businesses. They'll deny claims where ever they can - right or wrong.

Yeah, don't get me started on the system. The whole concept of health care INSURANCE is actually kind of bizarre. The whole concept of doing health care as a FOR PROFIT enterprise is kind of bizarre. For a reasonable level of personal income, sure, I don't mind M.D.s etc. who treat patients making good -- even very good -- salaries. But CEOs of insurance companies making mega-millions and M.D.s working for insurance companies being paid very high salaries and being given incentives to decline claims -- that just isn't right.

I am somewhat encouraged that the intake supervisor with whom I spoke sounded a bit outraged that the doctor performing the peer-to-peer had written only "waste of time" in his notes. Also, in California, if the appeal is denied, I can request an independent review from the California Department of Insurance.

It's particularly frustrating because Anthem approved it, we could have switched back to Anthem, but the surgical scheduler gave up the theater before we could make that happen. We'd set things up to have that option. So if one major insurer would have paid, another should be willing to as well. We have among the best plans going. I think there is some sour grapes about the Affordable Health Care Act being upheld involved. The denial occurred that very day.

This is all very confusing to me.

Your husband is in pain and needs surgery. So.... what's the issue that the insurance company is having?

Move to Canada. You'll never have to worry about it again.

Heck, out here the doctors send you for every test they can just to be sure that it's not something more serious.

Wait lists for surgery are pretty long, though...

Yeah, as a Canadian, no advice to give.