insurance is denying my back surgery fcking crooks

Big Bear · 01-10-20, 12:01 PM

Originally posted by DISTROYA

I have blue shield gold ppo califormia which I switched in the beginning of 2020. I am paying $900 a month just for myself. I submitted a claim for back surgery and they have denied it. Do I have any legal grounds to sue these bastards?
I have 2 torn disks in my lower back. I had epidural did not help last year. Have the MRI. The surgeon/doctor said would call and speak to them on Monday. Is there any chance change their decision or anything else that I can do?
I threw out my back so bad last month I went to UCLA emergency Room. I think they are denying because I did not go to physical therapy. I was never recommended this and I know that it won't help as I have tried it before how could physical therapy repair 2 torn fuckking disks?
Any advice would be greatly appreciated as I am in Dire Straits and in need of a surgery.

I don’t really have advice but I feel for you. Back pain is the worst!

I would contact an attorney for sure though

I can’t give advice based on the condition you are in

however once you get better I would try that machine where you hang upside down

also cryotherapy, massage, a new mattress, CBD Oil, and yoga.

Whatever you do, don’t take opioids

pologq · 01-10-20, 12:14 PM

agree no opioids!!

i have a bulging and sometimes herniated disc between L5 and S1. goes right into my groin and lower stomach with tightness and such. i feel for you. used to take motrin here and there but i don't even take anything anymore cause i have gotten used to the discomfort sadly and don't want to worry about my stomach and such.

i would get the reason as to why and then see an attorney with that paperwork. hopefully the doctor can convince them you need it before that needs to happen.

health insurance blows. all that money you pay and then you get a good ol' middle finger when you need it.

HockeyRocks · 01-10-20, 12:15 PM

Originally posted by DISTROYA

I have blue shield gold ppo califormia which I switched in the beginning of 2020. I am paying $900 a month just for myself. I submitted a claim for back surgery and they have denied it. Do I have any legal grounds to sue these bastards?
I have 2 torn disks in my lower back. I had epidural did not help last year. Have the MRI. The surgeon/doctor said would call and speak to them on Monday. Is there any chance change their decision or anything else that I can do?
I threw out my back so bad last month I went to UCLA emergency Room. I think they are denying because I did not go to physical therapy. I was never recommended this and I know that it won't help as I have tried it before how could physical therapy repair 2 torn fuckking disks?
Any advice would be greatly appreciated as I am in Dire Straits and in need of a surgery.

....You say you submitted a claim or did your doctor submit papers for pre-approval on your surgery?. Big difference.

BigdaddyQH · 01-10-20, 12:24 PM

Originally posted by DISTROYA

I have blue shield gold ppo califormia which I switched in the beginning of 2020. I am paying $900 a month just for myself. I submitted a claim for back surgery and they have denied it. Do I have any legal grounds to sue these bastards?
I have 2 torn disks in my lower back. I had epidural did not help last year. Have the MRI. The surgeon/doctor said would call and speak to them on Monday. Is there any chance change their decision or anything else that I can do?
I threw out my back so bad last month I went to UCLA emergency Room. I think they are denying because I did not go to physical therapy. I was never recommended this and I know that it won't help as I have tried it before how could physical therapy repair 2 torn fuckking disks?
Any advice would be greatly appreciated as I am in Dire Straits and in need of a surgery.

Just so I understand, you switched insurance in January of 2020, just 10 days ago, and NOW you are trying to put in a claim for what is an obvious pre-existing illness? If this is the case, you are lucky they just do not drop you. If your injury occurred before you switched insurnaces, then the previous insurer is still responsible under the continuing illness laws. If you did not report the previous illness to your new insurance company, you have no shot at collecting anything. Make sure you have your dates correct. If anything, Blue Shield can claim that you are trying to pull a scam. I can not believe that you would try to collect 10 days after taking the insurance out.

Okieirish · 01-10-20, 12:39 PM

I could buy a pretty nice house based on what I pay BCBS a month. I feel for you. It seems like a ripoff paying for it, especially when they try to stiff you when it's time to get something fixed. Like the other guy said, if there was never a lapse in coverage, I really believe one of those companies is paying. Any court would sympathize with you over an insurance company. They are crooks.

Ian · 01-10-20, 12:48 PM

Only advice I can give is to stay calm.

Just like with you, my mom was denied medical treatment by insurance for an issue last fall, but when the doctor spoke with the insurance company she got her treatment.

Also like you, I ruptured a disk in my back last summer. I went to physical therapy and with follow-up yoga I'm fine now. I'm sorry PT didn't work for you when you tried it in the past, but I'm writing this just so you don't feel hopeless if you are referred to PT again. It can work.

Best of luck to you.

HockeyRocks · 01-10-20, 01:10 PM

Originally posted by DISTROYA

I have blue shield gold ppo califormia which I switched in the beginning of 2020. I am paying $900 a month just for myself. I submitted a claim for back surgery and they have denied it. Do I have any legal grounds to sue these bastards?
I have 2 torn disks in my lower back. I had epidural did not help last year. Have the MRI. The surgeon/doctor said would call and speak to them on Monday. Is there any chance change their decision or anything else that I can do?
I threw out my back so bad last month I went to UCLA emergency Room. I think they are denying because I did not go to physical therapy. I was never recommended this and I know that it won't help as I have tried it before how could physical therapy repair 2 torn fuckking disks?
Any advice would be greatly appreciated as I am in Dire Straits and in need of a surgery.

You need to be more specific pardner. From what you have said, it appears what was denied was the pre-approval request for surgery from the doctor. That's an issue you beed to bring up with your doctor. The ins. company may want more information from the doctor. Don't jump until you have a full explanation from your doctor...

cincinnatikid513 · 01-10-20, 01:11 PM

900 a month thats crazy

hehfest · 01-10-20, 01:34 PM

Go to a chiropractor. It did wonders for me. I couldn't literally even walk and I kept going and kept getting better. Not saying it will be all you need, but it will help. Don't freak out because you will hear things cracking.....don't worry I won't set you up to have your kneecaps taken out.

hehfest · 01-10-20, 01:34 PM

Originally posted by DISTROYA

I have blue shield gold ppo califormia which I switched in the beginning of 2020. I am paying $900 a month just for myself. I submitted a claim for back surgery and they have denied it. Do I have any legal grounds to sue these bastards?
I have 2 torn disks in my lower back. I had epidural did not help last year. Have the MRI. The surgeon/doctor said would call and speak to them on Monday. Is there any chance change their decision or anything else that I can do?
I threw out my back so bad last month I went to UCLA emergency Room. I think they are denying because I did not go to physical therapy. I was never recommended this and I know that it won't help as I have tried it before how could physical therapy repair 2 torn fuckking disks?
Any advice would be greatly appreciated as I am in Dire Straits and in need of a surgery.

How did you injure it?

DISTROYA · 01-10-20, 02:38 PM

This is why I love this forum and all the posters. Great responses guys, thanks really. Let me try to comment or answer each post.
Big Bear.....I do have an inversion table....and a back brace, did epidural last year cost $3000.00 lasted 1 month free of pain. Ive had back problems ever since I first threw out in 2005, never forget that October day. I bent over to pick up something that I dropped and CRACK. I was 30 then now 45. Since then Ive done all I can...chiropractic (shelled out $5500 for spinal decompression in 2009 felt GREAT for one year then CRACK again its back.) acupunture (feels great when applied but not long term solution). Countless creams, massages of every oriental origin known to man; cold/hot packs. Stretching. Another doctor that said it starts with neck, neck must be aligned for back to heal, another waste of a year and money. Many different mattresses. Currently happy with a hard bed, the soft ones kill me. Even sleep on floor certain nights. Inversion table feels great but for how long....during day comes back again. I have 2 torn disks L5-S1 hanging upside down prob tears them more even though feels good. I do this 5-10 minutes a day.
Hockey rocks.....sorry I wasnt clear my doctor/surgeon submitted the paperwork and claim (the lady who helps me there). She said the doctor will call the insurance company on Monday and plead my case. I told her please deem it as a emergency/necessity. I submitted all the work (epidural, MRI, etc. ) to her and she said did you have physical therapy. I said no. She said oooh thats important. Right at that moment I said watch these assholes are gonna deny me because I didnt do physical therapy,even though did many other things and have a smoking gun MRI with a totally fuckked up back.
Ian-thanks for the encouragement I guess if no surgery will give it another chance. Im hoping the doctor speaking to them will convince them to change the decision.
Hehfest...no idea how it happened. I used to play lots of basketball in the heyday. Nothing terrible like an accident or fall. And have tried many chiros just doesnt help thanks though.
BigdaddyOH, the insurance laws in California prohibit denial of coverage based on a pre-existing condition. Filing a claim for health January 1 or June 1 when you are insured doesnt matter (at least thats what Ive been told). They do not have the right anymore to question anything pre-existing I believe in California. Thats precisely why I bent over backwards to take it up the ass and pay this ridiculous premium; to have a supposedly good health insurance.

HockeyRocks · 01-10-20, 03:03 PM

Originally posted by DISTROYA

This is why I love this forum and all the posters. Great responses guys, thanks really. Let me try to comment or answer each post.
Big Bear.....I do have an inversion table....and a back brace, did epidural last year cost $3000.00 lasted 1 month free of pain. Ive had back problems ever since I first threw out in 2005, never forget that October day. I bent over to pick up something that I dropped and CRACK. I was 30 then now 45. Since then Ive done all I can...chiropractic (shelled out $5500 for spinal decompression in 2009 felt GREAT for one year then CRACK again its back.) acupunture (feels great when applied but not long term solution). Countless creams, massages of every oriental origin known to man; cold/hot packs. Stretching. Another doctor that said it starts with neck, neck must be aligned for back to heal, another waste of a year and money. Many different mattresses. Currently happy with a hard bed, the soft ones kill me. Even sleep on floor certain nights. Inversion table feels great but for how long....during day comes back again. I have 2 torn disks L5-S1 hanging upside down prob tears them more even though feels good. I do this 5-10 minutes a day.
Hockey rocks.....sorry I wasnt clear my doctor/surgeon submitted the paperwork and claim (the lady who helps me there). She said the doctor will call the insurance company on Monday and plead my case. I told her please deem it as a emergency/necessity. I submitted all the work (epidural, MRI, etc. ) to her and she said did you have physical therapy. I said no. She said oooh thats important. Right at that moment I said watch these assholes are gonna deny me because I didnt do physical therapy,even though did many other things and have a smoking gun MRI with a totally fuckked up back.
Ian-thanks for the encouragement I guess if no surgery will give it another chance. Im hoping the doctor speaking to them will convince them to change the decision.
Hehfest...no idea how it happened. I used to play lots of basketball in the heyday. Nothing terrible like an accident or fall. And have tried many chiros just doesnt help thanks though.
BigdaddyOH, the insurance laws in California prohibit denial of coverage based on a pre-existing condition. Filing a claim for health January 1 or June 1 when you are insured doesnt matter (at least thats what Ive been told). They do not have the right anymore to question anything pre-existing I believe in California. Thats precisely why I bent over backwards to take it up the ass and pay this ridiculous premium; to have a supposedly good health insurance.

Under curent law health ins. coms. can't refuse to cover you or charge you more just because you have a pre-existing condition.
That can't limit benefits for that condition either.
They also can't refuse to cover treatment for that pre-existing condidion either...
Hurry though, because trump is trying to destroy these benefits now. A court is due to rule on this anytime.

Just one question. Have you had health ins. for 18 consecutuive months?

DISTROYA · 01-10-20, 03:06 PM

oh yeah had insurance for years and years. Actually I never not had it. I had a crappy plan under obamacare last year. Since my income threshold changed they threw me out from there, so I switched to what I thought was a great plan. I was even told by the doctors office this is the one they prefer.

HockeyRocks · 01-10-20, 03:22 PM

Originally posted by DISTROYA

oh yeah had insurance for years and years. Actually I never not had it. I had a crappy plan under obamacare last year. Since my income threshold changed they threw me out from there, so I switched to what I thought was a great plan. I was even told by the doctors office this is the one they prefer.

Like i say, if you have an experienced surgeon he should know how to get your surgery approved....Good luck..

DISTROYA · 01-10-20, 03:37 PM

Boy is he....does all the top sports athletes in SoCal. He actually operated on my dad last year; he was hunched over severely but day after surgery like never happened. Thats why I want him to operate. A family member works for NFL so got the connections through there or else he wont even take on new patients. On pins and needles till next week, when I get an update. Thanks Hockey.

Salam · 01-10-20, 03:49 PM

go to china they'll do it for cheap

DISTROYA · 01-10-20, 04:06 PM

seriously not a bad idea. maybe not china but what other countries can do a good job and I cut through this nonsense just get it done. It would be a vacation and surgery and prob still cost much less than what I have to pay out of pocket.

DISTROYA · 01-28-20, 01:24 AM

Looks like doc spoke and insurance reversed their decision. Having double fusion surgery next week. Has anyone had?

CWD · 01-28-20, 05:37 AM

pologq · 01-28-20, 07:59 AM

Originally posted by DISTROYA

Looks like doc spoke and insurance reversed their decision. Having double fusion surgery next week. Has anyone had?

are they fusing two discs together?

gauchojake · 01-28-20, 10:09 AM

Originally posted by DISTROYA

Looks like doc spoke and insurance reversed their decision. Having double fusion surgery next week. Has anyone had?

congrats

I wish I saw this earlier but HockeyRocks gave you the same info I would have.

The insurance company cannot deny a procedure that is "medically necessary" unless it's experimental or not traditionally approved. Your doctor's office is in the business of getting paid for these procedures so they obv know how to appeal the denials.

Just remember that these people (ins co) get paid to deny medical care. They are like the mafia.

RudyRuetigger · 01-28-20, 10:13 AM

Originally posted by DISTROYA

Looks like doc spoke and insurance reversed their decision. Having double fusion surgery next week. Has anyone had?

good luck bro

back is my main fukkin problem

was considering an inversion table

DISTROYA · 01-28-20, 11:29 AM

Thx guys. 16 years of pain hope coming to an end. I will be breifed and prepped pre-op on 5th...surgery on 6th.
Never been so anxious. This doc has operated on major sports figures in L.A. got some pull cause family member works at a sports network.
Rudy I have inversion table it feels good but with 2 torn discs not a permanent solution. It may have even caused them to tear more by stretching who knows.

Ian · 01-28-20, 01:33 PM

Originally posted by DISTROYA

Thx guys. 16 years of pain hope coming to an end. I will be breifed and prepped pre-op on 5th...surgery on 6th.
Never been so anxious. This doc has operated on major sports figures in L.A. got some pull cause family member works at a sports network.
Rudy I have inversion table it feels good but with 2 torn discs not a permanent solution. It may have even caused them to tear more by stretching who knows.

That's awesome that your doctor was able to help you get your surgery. Best of luck, distroya!

hehfest · 01-28-20, 01:48 PM

There is always an option of Final Rage.

bitcoinLuke · 01-28-20, 04:10 PM

All insurance carriers make you try ever possible option before surgery. Had the same thing happen to me. Did PT (6-8 weeks), then got 2 shots in the back, then PT again, then another shot, then they finally approved the surgery. Between waiting for dr appts, shots and PT (twice), it was was year and a half before the surgery was approved. You'll probably have to go to PT(it wont work)for them to approve it.

Hope you feel better soon

Shute · 01-28-20, 07:18 PM

Medical insurance a bunch crooks

DISTROYA · 02-12-20, 11:57 AM

Hi guys just an update I had my surgery last Thursday it went very well it's going to take about 4 to 6 weeks to get back to work. I was in a lot of pain the 1st few days but feeling a lot better now I'm just glad it's finally over look forward to a mostly pain free life the rest of the way have a long journey ahead for the spine and bone to fuse and heal. Thanks for everyone's support and help on this thread.

eaglesfan371 · 02-12-20, 09:50 PM

I hope you get approved but from a finance perspective this one smells...

Upgrades to an expensive healthcare plan

Month later needs very expensive surgery

Sounds like pre-existing condition

DISTROYA · 02-13-20, 11:04 AM

Hey Eagles; I had mentiuoned first they denied but then approved. I have a 5k deductible, and in addition the surgeon fee was 30,000 which i was responsible for half, so plunked down 15k because he was out of network. I didnt care no price can value the pain Ive suffered 16+ years, so glad I had it done. I literally had 1 disc level eroded they told me it was bone level on bone and gonna get much worse if not corrected. I also grew about an inch lol or it feels. Slowly walking, getting in out bed. No bending over or range of motion twisting yet. So prob gonna cost me a good 20-25k all said and done outta pocket, even with a premium gold blue shield ppo insurance in which Im paying 700+ month just for me. Cali sucks.

HockeyRocks · 02-13-20, 11:09 AM

Originally posted by DISTROYA

Hey Eagles; I had mentiuoned first they denied but then approved. I have a 5k deductible, and in addition the surgeon fee was 30,000 which i was responsible for half, so plunked down 15k because he was out of network. I didnt care no price can value the pain Ive suffered 16+ years, so glad I had it done. I literally had 1 disc level eroded they told me it was bone level on bone and gonna get much worse if not corrected. I also grew about an inch lol or it feels. Slowly walking, getting in out bed. No bending over or range of motion twisting yet. So prob gonna cost me a good 20-25k all said and done outta pocket, even with a premium gold blue shield ppo insurance in which Im paying 700+ month just for me. Cali sucks.

Who paid the other half of the surgeons fee. You said he was out of network? Or did he write it off?

DISTROYA · 02-13-20, 11:23 AM

the plan covered 50% out of network surgeon fee. (spinal fusion.)

gauchojake · 02-13-20, 12:19 PM

You might be able to claim a tax deduction for your out of pocket. Check with your tax guy. Hope you feel better.

stevek173 · 02-13-20, 01:05 PM

Sounds like a rough ride for sure.

All the best man.