Blue Cross Rejects Critical Surgery for Orange County ICU Nurse

Munchkin315 · Mar 10, 2008

This is why I hate insurence companies...I hope that she gets the surgery that she needs.

Simplepleasures · Mar 10, 2008

Wow, Blue Cross approved it for a 26 year old, but denied as experimental in a 46 year old? Im calling, now. I know what kind of pain she must be in, I also have DDD and DJD in multilevels of spine and I am disabled.

sheluke · Mar 10, 2008

Ok, once again may resent this, and I am not defending BC, but saying there is a due process that can be followed to ensure this is resolved appropriately- Though I am all for a good appeal when a decision seems wrong...I would discourage anyone from flooding the case manager at BC with calls. I assure you, the case manager does not have authority to have denied this surgery, and is a nurse too and needs to spend her day working with her patient population to do whatever she can for them. She cannot change the decision either, that's not the way to go.

The BC policy is actually quite clear about what is considered investigational still with this procedure, and since the article about Ms Kutcher does not go into the level of disc, etc, we really have no idea if the policy was followed in terms of meeting criteria or not.

The family and the physicians need to file the appeal, with good documentation of why this is necessary.

Most insurance companies do technical assessments of new treatments, new devices, etc, based on many resources other than just FDA approval. There are minimal trials necessary big companies (for profit) know how to do a trial and get through the fda process. There are other clinical sources as well.

Believe me, I am absolutely not a fan of any of the 'Blues-however, we do not know the whole story and I have in my experiences elsewhere seen too many occasions where documentation wasn't provided by the surgeon when requested, or newer treatments were being requested that were truly not the standard of care commonly accepted in an authoritative body of physicians (ie one may be wanting to do a procedure and saying he/she is innovative and cutting edge, while the rest of the story may be that the other 9 out of 10 physicians do not believe procedure safe, or have concerns long term, etc) This is putting a foreign body into your spine, nothing to be taken lightly.

Anyone that is interested in the actual Blues policy-here's what they say:

http://www.bluecrossca.com/medicalpolicies/policies/mp_pw_a053354.htm

bollweevil · Mar 10, 2008

Ok, once again may resent this, and I am not defending BC, but saying there is a due process that can be followed to ensure this is resolved appropriately- Though I am all for a good appeal when a decision seems wrong...I would discourage anyone from flooding the case manager at BC with calls. I assure you, the case manager does not have authority to have denied this surgery, and is a nurse too and needs to spend her day working with her patient population to do whatever she can for them. She cannot change the decision either, that's not the way to go.
The BC policy is actually quite clear about what is considered investigational still with this procedure, and since the article about Ms Kutcher does not go into the level of disc, etc, we really have no idea if the policy was followed in terms of meeting criteria or not.
The family and the physicians need to file the appeal, with good documentation of why this is necessary.
Most insurance companies do technical assessments of new treatments, new devices, etc, based on many resources other than just FDA approval. There are minimal trials necessary big companies (for profit) know how to do a trial and get through the fda process. There are other clinical sources as well.
Believe me, I am absolutely not a fan of any of the 'Blues-however, we do not know the whole story and I have in my experiences elsewhere seen too many occasions where documentation wasn't provided by the surgeon when requested, or newer treatments were being requested that were truly not the standard of care commonly accepted in an authoritative body of physicians (ie one may be wanting to do a procedure and saying he/she is innovative and cutting edge, while the rest of the story may be that the other 9 out of 10 physicians do not believe procedure safe, or have concerns long term, etc) This is putting a foreign body into your spine, nothing to be taken lightly.
Anyone that is interested in the actual Blues policy-here's what they say:
http://www.bluecrossca.com/medicalpolicies/policies/mp_pw_a053354.htm

Interesting. I had no idea that artificial disks had become available.

I really wish this nurse could have non-surgical interviention, such as spinal axial decompression (high-tech, mechanized traction, intermittent) and wonder if she's tried that.

It was interesting reading their policy. At first, it sounds reasoned. I still think they are monsters to deny anyone a chance at pain relief, preservation of motion, and the opportunity to get back to work but thank you for posting this. IT was interesting and informative.

And if the CM isn't the one to call, who should we call? You must have some experience in this field. Thank you.

JaneyW · Mar 10, 2008

I am a nurse who has returned to work after a spinal fusion and know many others. My surgery was 5 years ago, though, and this may be the newer better treatment. I just know that the fusion solved my pain issues well. I would say that if Kaiser is approving it, it probably has some merit. I hope she gets what she needs.

Do you really think that a government based system is going to be friendlier to new procedures? Or faster in approving them? Have you ever worked for the government? There is no such thing as fast or efficient. There is no motivation for them to be fast and efficient and no recourse if they are not.

core0 · Mar 10, 2008

Ok, once again may resent this, and I am not defending BC, but saying there is a due process that can be followed to ensure this is resolved appropriately- Though I am all for a good appeal when a decision seems wrong...I would discourage anyone from flooding the case manager at BC with calls. I assure you, the case manager does not have authority to have denied this surgery, and is a nurse too and needs to spend her day working with her patient population to do whatever she can for them. She cannot change the decision either, that's not the way to go.
The BC policy is actually quite clear about what is considered investigational still with this procedure, and since the article about Ms Kutcher does not go into the level of disc, etc, we really have no idea if the policy was followed in terms of meeting criteria or not.
The family and the physicians need to file the appeal, with good documentation of why this is necessary.
Most insurance companies do technical assessments of new treatments, new devices, etc, based on many resources other than just FDA approval. There are minimal trials necessary big companies (for profit) know how to do a trial and get through the fda process. There are other clinical sources as well.
Believe me, I am absolutely not a fan of any of the 'Blues-however, we do not know the whole story and I have in my experiences elsewhere seen too many occasions where documentation wasn't provided by the surgeon when requested, or newer treatments were being requested that were truly not the standard of care commonly accepted in an authoritative body of physicians (ie one may be wanting to do a procedure and saying he/she is innovative and cutting edge, while the rest of the story may be that the other 9 out of 10 physicians do not believe procedure safe, or have concerns long term, etc) This is putting a foreign body into your spine, nothing to be taken lightly.
Anyone that is interested in the actual Blues policy-here's what they say:
http://www.bluecrossca.com/medicalpolicies/policies/mp_pw_a053354.htm

Not for or against this. As much as I would hate to ever side with Blues, there are some issues with the artificial discs. The NYTimes had a number of articles on this in January:

http://www.nytimes.com/2008/01/30/business/30spine.html

Not saying its good or bad. However, there are a number of questions to be answered here.

David Carpenter, PA-C

FireStarterRN, BSN, RN · Mar 11, 2008

It sounds like ageism to me.

bollweevil · Mar 11, 2008

Not for or against this. As much as I would hate to ever side with Blues, there are some issues with the artificial discs. The NYTimes had a number of articles on this in January:
http://www.nytimes.com/2008/01/30/business/30spine.html
Not saying its good or bad. However, there are a number of questions to be answered here.
David Carpenter, PA-C

Enlightening. Of course, let's remember that this is only 1 of the several artificial disks that are available.

HM2VikingRN, RN · Mar 11, 2008

I am not sure how this was turned into a referendum on single payer. I think that the post spoke more to the problems of unreasonable denial of care based on what appears to be ageism.

jeolsz · Mar 14, 2008

Kudos to Sheluke for reminding everyone that there are 2 sides to every story. I gotta tell you, I have Blue Cross and I have never had a problem with coverage.. I've always found them very easy to deal with and easy to contact. Now I will admit I've never had a complicated procedure or a surgery that needed precert, but being that I do work for a health insurance company ( and it's not Blue Cross believe it or not!) I do understand the process and what goes on behind the scenes and they always get a bad rap. It's like working for the IRS. it's an agency people love to hate!

On a different note, I hope the nurse who is suffering from back problems finds relief, as I know how debilitating back pain can be.