Have major back surgery planned for Fri- can’t do it because it’s not covered by insurance

Wag · Jan 14, 2020

Pretty pissed right now. Have major back surgery planned for fri, been working with this surgeon for well over the year. This surgeon and 2 previous surgeons I saw told me I needed it. Now I find out at the last minute this surgeon considers the surgery as elective so my insurance covers none of it. Maybe I'm stupid but "need" and "necessity" is the same thing.

This is at a major Boston metro hospital.

I am in agony and have been for most of my adult life. I've expended every other form of medical treatment. This was my last option. I don't want to be disabled for the rest of my life. I need to work.

The American medical system sucks.

echoshifting · Jan 14, 2020

Have you talked to the surgeon? Sounds like you need to find a surgeon who won't submit it as elective.

May I ask what kind of surgery, or do you want to keep that private? I've had a lot of back surgery to treat pain, and this has never happened to me.

_Karooo · Jan 14, 2020

Sorry dude. Try to get a note from a different surgeon from a different hospital that the surgery is indeed required.

Agent 47 · Jan 14, 2020

God bless the land of the free.

NoblesseOblige · Jan 14, 2020

that's fucked. any surgery reducing a person's pain should not be considered 'elective' in a civilized world.

Volimar · Jan 14, 2020

Seems like the surgeon might have tanked it for you. You might have to find one who will sign off but it could make it a fight now that they have a reason to deny it.

Wag · Jan 14, 2020

echoshifting said:
Have you talked to the surgeon? Sounds like you need to find a surgeon who won't submit it as elective.

May I ask what kind of surgery, or do you want to keep that private? I've had a lot of back surgery to treat pain, and this has never happened to me.

I'm trying to get a hold of them again now. The surgeon called me a couple of weeks ago and we discussed it. Nobody ever told me this was an elective surgery. It's lower lumbar fusion. The nurse who works with him relayed it was elective this morning after I called insurance.

fluffydelusions · Jan 14, 2020

Speaking of screwed up backs I have to get a steroid injection in my back on Friday...can't wait

Loxley · Jan 14, 2020

Wag said:
I'm trying to get a hold of them again now. The surgeon called me a couple of weeks ago and we discussed it. Nobody ever told me this was an elective surgery. It's lower lumbar fusion. The nurse who works with him relayed it was elective this morning after I called insurance.

Yeah I would find another surgeon. If it's as bad as you say and you'll end up disabled without the surgery, there's no way in hell it would ever be considered "elective".

Wag · Jan 14, 2020

Loxley said:
Yeah I would find another surgeon. If it's as bad as you say and you'll end up disabled without the surgery, there's no way in hell it would ever be considered "elective".

This is kind of hard to do when one of the best neurosurgeons for back surgery in the world lists a procedure as an elective.

fatigues_gasolini · Jan 14, 2020

You should be able to appeal this at your insurance company. Have the surgeons send medical records over and have them write a note that it isnt elective. Insurance companies will do anything not to pay something and sometimes require an appeal with additional information to get them to pay for it.

echoshifting · Jan 14, 2020

Wag said:
I'm trying to get a hold of them again now. The surgeon called me a couple of weeks ago and we discussed it. Nobody ever told me this was an elective surgery. It's lower lumbar fusion. The nurse who works with him relayed it was elective this morning after I called insurance.

Oof, that really sucks. Sounds like it is normal for fusions to be considered "elective but medically necessary," whatever that means. Well good luck on the phone today. Definitely call around your insurance company, too. You might need to petition. If this doesn't work out and you need an alternative, please feel free to PM me and we can talk about spinal cord stimulators. Fight and advocate for yourself through this, but if it doesn't work out, don't give up hope.

collige · Jan 14, 2020

I actually just got back from talking to a surgeon about lumbar fusion and the idea that anyone would consider it "elective" is hilarious to me. My condolences OP, I would be enraged in your situation.

fluffydelusions said:
Speaking of screwed up backs I have to get a steroid injection in my back on Friday...can't wait

Injections are super simple, I've done them a bunch of times. Don't stress about it.

BringBackSonics · Jan 14, 2020

Wag said:
Pretty pissed right now. Have major back surgery planned for fri, been working with this surgeon for well over the year. This surgeon and 2 previous surgeons I saw told me I needed it. Now I find out at the last minute this surgeon considers the surgery as elective so my insurance covers none of it. Maybe I'm stupid but "need" and "necessity" is the same thing.

This is at a major Boston metro hospital.

I am in agony and have been for most of my adult life. I've expended every other form of medical treatment. This was my last option. I don't want to be disabled for the rest of my life. I need to work.

The American medical system sucks.

Why did the surgeon change his mind? Maybe go back to the previous surgeon who said you needed it? Is this some form of experimental surgery ?

SasaBassa · Jan 14, 2020

I feel for you, that's fucking ridiculous.

Outside of the size of the corporations and fast food value meals , what is honestly first world about the US when shit as bad as this can happen?

Deleted member 43 · Jan 14, 2020

Wag said:
This is kind of hard to do when one of the best neurosurgeons for back surgery in the world lists a procedure as an elective.

You need to talk to the doc, this doesn't make much sense.

fluffydelusions · Jan 14, 2020

collige said:
Injections are super simple, I've done them a bunch of times. Don't stress about it.

I'm just wondering if it will work tbh. I have constant pins and needles and numbness in my feet and I've taken steroids and muscle relaxers tons of times over the years and they always said it would go away in a couple days and it never did anything so I'm hoping this isn't a waste of time as well.

echoshifting · Jan 14, 2020

Matt said:
You need to talk to the doc, this doesn't make much sense.

I did a bit of googling and it sounds normal:

Elective surgery can be medically necessary. "Elective" just means that surgery of the spine is rarely an absolute necessity. Only in rare instances, such as for patients who have a progressive neurological loss of function or sudden onset of bowel or bladder incontinence, is spinal surgery actually necessary on an emergency basis.

https://www.spine-health.com/treatment/back-surgery/back-surgery-and-neck-surgery-overview

Sounds like this is more on the insurance company than the doc.

collige · Jan 14, 2020

fluffydelusions said:
I'm just wondering if it will work tbh. I have constant pins and needles and numbness in my feet and I've taken steroids and muscle relaxers tons of times over the years and they always said it would go away in a couple days and it never did anything so I'm hoping this isn't a waste of time as well.

Muscle relaxers have never done anything for me but injections definitely helped and AFAIK it's generally the next step after meds for spinal issues. In my case (sciatica) I can actually "feel" the injection going down into my leg when they put it in. It's a weird sensation, but you can definitely tell it's hitting the right spot.

Raguel · Jan 14, 2020

Sorry to hear about all this shit. Fuck the American health care. Def call your insurance to complain and petition. And your doc.

If you make a big enough stink, insurance will sometimes cover.

fluffydelusions · Jan 14, 2020

collige said:
Muscle relaxers have never done anything for me but injections definitely helped and AFAIK it's generally the next step after meds for spinal issues. In my case (sciatica) I can actually "feel" the injection going down into my leg when they put it in. It's a weird sensation, but you can definitely tell it's hitting the right spot.

Did you ever try oral steroids? I tried those and they did nothing as well. Hoping the shot will give me some relief though.

Freakzilla · Jan 14, 2020

You're gonna have to appeal. I think my dad had issues when they fused b parts of his spine becausenof Anklyosing spondilitis

Walter White Walker · Jan 14, 2020

Loxley said:
Yeah I would find another surgeon. If it's as bad as you say and you'll end up disabled without the surgery, there's no way in hell it would ever be considered "elective".

Hearing aids for deaf children are considered "elective." Just saying.
I'm hoping you get this figured out, OP.

Wag · Jan 14, 2020

fluffydelusions said:
I'm just wondering if it will work tbh. I have constant pins and needles and numbness in my feet and I've taken steroids and muscle relaxers tons of times over the years and they always said it would go away in a couple days and it never did anything so I'm hoping this isn't a waste of time as well.

Never worked for me for more than a day or so, one of the reasons why I'm having surgery. It's worth a shot though, surgery is always the last option.

BringBackSonics · Jan 14, 2020

I would go over the insurance policy with your surgeon's office, to see why it is not medically necessary. I'm sorry this is happening to you, I would have thought the surgeon would have reviewed this way before a few days before the surgery. Usually the office will figure out the insurance stuff long before the procedure date.

Deleted member 43 · Jan 14, 2020

echoshifting said:
I did a bit of googling and it sounds normal:

https://www.spine-health.com/treatment/back-surgery/back-surgery-and-neck-surgery-overview

Sounds like this is more on the insurance company than the doc.

The point is "elective" vs. "necessary" isn't generally the sole consideration for insurance. If the pain is debilitating enough to limit the OP's ability to work, that should be enough to cover it.

Which means the surgeon might not know his designation is causing insurance not to cover it, and they might change that if made aware.

Also, a doctor personally contacting the insurance company and advocating for a procedure can often make them reverse a ruling.

echoshifting · Jan 14, 2020

Matt said:
The point is "elective" vs. "necessary" isn't generally the sole considerations for insurance. If the pain is debilitating enough to limit the OP's ability to work, that should be enough to cover it.

Which means the surgeon might not know his designation is causing insurance not to cover it, and they might change that if made aware.

Oh yeah, true. I mistook your meaning.

collige · Jan 14, 2020

fluffydelusions said:
Did you ever try oral steroids? I tried those and they did nothing as well. Hoping the shot will give me some relief though.

Yeah, didn't help at all, but injections were on a completely different level for me. Hope yours goes well.

BringBackSonics · Jan 14, 2020

echoshifting said:
Sounds like this is more on the insurance company than the doc.

The Doctor's office should have known if they have been working with the OP for a year.

Wag · Jan 14, 2020

Spoke to the surgeons office- they're telling me it shouldn't be a problem. But the surgery is still considered "elective" and Medicare only covers back surgery that's deemed as "medically necessary". They're going to contact financial services and try to sort it out.

I will be on the phone all day today.

BringBackSonics · Jan 14, 2020

Wag said:
Spoke to the surgeons office- they're telling me it shouldn't be a problem. But the surgery is still considered "elective" and Medicare only covers back surgery that's deemed as "medically necessary". They're going to contact financial services and try to sort it out.

I will be on the phone all day today.

OP, did your insurance company say why it wasn't medically necessary? Usually they also want you to jump through a shit ton of hoops, before approving surgery (rehab/therapy etc)

Good luck to you

NinjaScooter · Jan 14, 2020

How in the fuck to they manage to spin the fact that someone would be having a spinal fusion surgery "electively"? Fucking insurance companies and Medical professionals ain't shit.

Wag · Jan 14, 2020

BringBackSonics said:
OP, did your insurance company say why it wasn't medically necessary? Usually they also want you to jump through a shit ton of hoops, before approving surgery (rehab/therapy etc)

Good luck to you

Not up to the insurance. The surgeon said it was elective.

Jon Carter · Jan 14, 2020

Fucking hell, I've been here for well over a decade and I'm still surprised at times when these things happen.

For me personally, even though I'm no longer covered in France since I don't live there anymore, I always go back when I need to do something expensive. A lot of the time, it's less expensive there even without insurance than it is here.

I don't know how much it would cost without insurance in the U.S. and abroad. Is Canadian health care without insurance also just as expensive?

BringBackSonics · Jan 14, 2020

Wag said:
Not up to the insurance. The surgeon said it was elective.

Well that is true, but even elective surgeries can be medically necessary.

Rebel1 · Jan 14, 2020

At lease you have CHOICE unlike those other countries

Kill3r7 · Jan 14, 2020

Sorry to hear that OP. Although, given that MA has arguably the best healthcare in the country I would hate to think how the rest of us would fare.

GulAtiCa · Jan 14, 2020

Damn, that sucks. hope you can get it fixed?

fluffydelusions said:
Speaking of screwed up backs I have to get a steroid injection in my back on Friday...can't wait

An Epidural Lumbar Injection? I had (well, still have) herniated disk last year and had to get 3 shots. Totally easy. 99% painless too. the whole thing from 1st numbing shot to them saying your done is like 2 minutes tops. You might feel the numbing shot, but like a super quick small pinch. I only ever felt it the 1st time I wen, never did for the other 2.

fluffydelusions said:
I'm just wondering if it will work tbh. I have constant pins and needles and numbness in my feet and I've taken steroids and muscle relaxers tons of times over the years and they always said it would go away in a couple days and it never did anything so I'm hoping this isn't a waste of time as well.

For my issue, only shots ever worked. No medicine (besides a small opoied) ever helped with the pain. The lumbar shots and anytime I would go get a regular colitizoid shot in butt would help (the butt shots only help a few short days and eventually stopped helping me).

Have you consider PT for your issues? That is what got me back in working mode again. Took many months, but finally got there

Douche McBaggins The 4th · Jan 14, 2020

fluffydelusions said:
I'm just wondering if it will work tbh. I have constant pins and needles and numbness in my feet and I've taken steroids and muscle relaxers tons of times over the years and they always said it would go away in a couple days and it never did anything so I'm hoping this isn't a waste of time as well.

Try lyrica. That helps the nerves but it is expensive medicine.

Wag · Jan 14, 2020

Jon Carter said:
Fucking hell, I've been here for well over a decade and I'm still surprised at times when these things happen.

For me personally, even though I'm no longer covered in France since I don't live there anymore, I always go back when I need to do something expensive. A lot of the time, it's less expensive there even without insurance than it is here.

I don't know how much it would cost without insurance in the U.S. and abroad. Is Canadian health care without insurance also just as expensive?

I don't know about abroad but an inpatient procedure like this here after all the aftercare and services will be well >$100k. So even if my secondary insurance picks up the 20% (which they probably won't) I still couldn't afford it.

I'm still hoping this is some sort of misunderstanding and it will work out.

fluffydelusions · Jan 14, 2020

Wag said:
Never worked for me for more than a day or so, one of the reasons why I'm having surgery. It's worth a shot though, surgery is always the last option.

collige said:
Yeah, didn't help at all, but injections were on a completely different level for me. Hope yours goes well.

Are you guys talking about it not helping back pain or pins and needles/numbness in feet? My back is screwed up but the pins and needles and numbness feeling in the feet is far more uncomfortable for me.

mcfizzle · Jan 14, 2020

Do you mind sharing a little bit what the condition is? Have you found a good physical therapist to work with?

Lumbar fusion is a surgery that I would do everything I can to avoid as it tends to create more problems than it fixes. The outcomes with it are not great.

Wag · Jan 14, 2020

fluffydelusions said:
Are you guys talking about it not helping back pain or pins and needles/numbness in feet? My back is screwed up but the pins and needles and numbness feeling in the feet is far more uncomfortable for me.

You're having sciatic pain which means your spine/discs are pushing up against the sciatic nerve. The medicine in the injections is supposed to relieve some of the inflammation that's causing the pain. It doesn't work for everyone but it's worth trying.

fluffydelusions · Jan 14, 2020

Wag said:
You're having sciatic pain which means your spine/discs are pushing up against the sciatic nerve. The medicine in the injections is supposed to relieve some of the inflammation that's causing the pain. It doesn't work for everyone but it's worth trying.

Yeah. Hoping for the best.

meowdi gras · Jan 14, 2020

Wag said:
I'm trying to get a hold of them again now. The surgeon called me a couple of weeks ago and we discussed it. Nobody ever told me this was an elective surgery. It's lower lumbar fusion. The nurse who works with him relayed it was elective this morning after I called insurance.

Is this a lower lumbar fusion without or with "instrumentation" (i.e., rods, screws, etc.)? Because I don't know about the former, but my bestie had the latter surgery some years ago after breaking her back on the job, and if she hadn't had it, she'd basically be bedridden. Calling this "elective" is fucking bullshit.

As a lot of things in life (unfortunately), you may have to resort to a lot of screaming to get what you need. Don't let up until you get that procedure covered.

GulAtiCa · Jan 14, 2020

Wag said:
You're having sciatic pain which means your spine/discs are pushing up against the sciatic nerve. The medicine in the injections is supposed to relieve some of that pain. It doesn't work for everyone but it's worth trying.

Yep. Mine was sciatic , pretty horrible too.

My 1st shot did wonders, made it so i can live again.
2nd shot, few months later did nothing, likely cause 1st shot was so helpful that 2nd wasn't able to help much.
3rd and last was the trick. It was actually a given from the side directly into the space where inflamed spine nerves were.

With the last one, I was finally able to improve with PT. Each week, I got a little bit better. I had to push through a lot to just be able to walk for like 3 minutes on the treadmill. Finally got the ability to drive on my own again to where I am now. Probably took me like 3 months or so to fully recover. It's a long long battle.

I hope all of you are able to recover

Wag · Jan 14, 2020

mcfizzle said:
Do you mind sharing a little bit what the condition is? Have you found a good physical therapist to work with?

Lumbar fusion is a surgery that I would do everything I can to avoid as it tends to create more problems than it fixes. The outcomes with it are not great.

I had a laminectomy for a ruptured disc when I was 24 (I'm 51 now). I was never the same afterwards. Over time I developed two small fractures in my lower back. Approx 2yrs ago my right thigh went numb. It's incredibly painful and makes it very difficult to drive (back surgery probably won't help this, there doesn't appear to be any treatment). My lower back always hurts, as well as my right hip and thigh. Tried everything, years of pt, multiple rounds of injections, lost a lot of weight, nothing has helped.

PeakPointMatrix · Jan 14, 2020

I'm so fucking embarrassed for my country. What a national shame this shit is.

collige · Jan 14, 2020

fluffydelusions said:
Are you guys talking about it not helping back pain or pins and needles/numbness in feet? My back is screwed up but the pins and needles and numbness feeling in the feet is far more uncomfortable for me.

Basically what OP said: the feet pain is back pain, it's all coming from the same place. In my case, it was burning pain in my left calf that was the worst part.

Douche McBaggins The 4th said:
Try lyrica. That helps the nerves but it is expensive medicine.

Lyrica went generic earlier this year, thankfully so it's in line with normal medicine. I got super lucky since the generic version came out about a week before I went on it.

Bakercat · Jan 14, 2020

Yeah, it took me 10 months for Insurance to be willing to do a second MRI and then surgery for my herniated L4-L5. I was walking around with a cane in my 20's with constant nerve pain. Worst part is that this was Medicaid...

I'm sorry to hear your situation OP. I know from first experience this shit fucking sucks.

Have major back surgery planned for Fri- can’t do it because it’s not covered by insurance

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