Your back is one of the most sensitive areas of your body. Issues related to the spinal cord, nerve endings, and discs along your lower back can cause mobility issues, chronic pain, and loss of productivity at work. Back complications often arise due to disc problems along the spinal cord- such as a herniated disc. They can also occur when there’s overgrowth in bone density or damaged nerve endings.
While more conservative treatment methods are preferable for back issues, the problems mentioned above may persist even after nonsurgical procedures are carried out. Therefore, back surgery may be your only option to enjoy relief from the symptoms of chronic back pain.
Unfortunately, back surgery is a very expensive procedure (costing over $100,000 on average). While many health insurance companies include back surgery in their coverage policies, it is not uncommon for a patient to be denied coverage for such a procedure. Insurance coverage for back surgery will depend on many different factors, including your specific health insurance policy, any pre-existing conditions, and your recommended treatment plan. In fact, insurance policies vary so widely from patient to patient, that it can be challenging to establish a standard for whether your back surgery costs will be covered or denied by the insurance company.
If your insurance company denies you back surgery coverage, you can appeal the decision based on a variety of factors. For example, you can talk with your surgeon to provide sufficient medical grounds for the procedure. You can also work with a law firm to ensure that you prepare a strong enough appeal to have the denial decision reversed.
What is Back Surgery?
Back surgery refers to a collection of procedures aimed at relieving pain and discomfort along your back and spinal cord. Such pain is often caused by spinal issues, nerve complications, or bone misalignment. Back surgery may be the best alternative to relieving persistent and disabling pain. Such pain not only affects the spinal cord itself, but it may also spread to your lower back, arms and legs.
Most back pain issues are caused by compressed nerves, which in turn relay pain signals to the brain. Nerve compression is often a result of a herniated disc or excessive bone growth along the back. With such conditions, back surgery can be used to relieve pain and to improve mobility. In fact, back surgery comes in handy for more than just pain relief.
Patients who undergo successful back surgery can also enjoy the following health benefits:
Increased physical fitness due to a healthier back and lower levels of pain
Being more productive at home and at work
With a healthier back, patients can become more self-sufficient at home and at work. They can keep up with house chores better, care for any children, and also become better employees.
No need to take lots of pain medication
With a successful back surgery procedure, patients don’t have to frequently take pain pills that may result in harmful side effects after each dose.
A better overall mood
A lot of debate surrounds back surgery and whether it’s the right procedure for you. While other non-invasive options such as physical therapy are effective, surgery may be your best alternative to achieving optimal results in a timely fashion. This is why it’s important to appeal any decision by your health insurance company that denies you coverage for back surgery.
Types of Back Surgery
There are four main types of back surgery that can be carried out. Depending on your specific ailment and overall health, your doctor will recommend the surgical procedure that will best yield effective results. As a patient, you should also understand what each surgical procedure involves and how you can play a part in determining the best one for your lower back issues.
The spinal cord is composed of a series of bones called vertebrae that help keep an upright posture along your back. To reduce friction between adjacent bones, a cushioned disc typically separates the vertebrae and acts as a shock absorber.
Many patients experience a condition where the disk slips out of place and exerts pressure on the spinal nerves. This is a common cause of back pain (and the condition is typically referred to as a herniated disc).
During a discectomy, all or part of the misplaced disc is removed. An incision is made along your back (near the affected area) to get to the affected disc. In most cases, discectomies have become less invasive because only a small incision is necessary for the surgeon to get to the affected area.
- Spinal Fusion
Spinal fusion refers to the connection of two or more bones in your spine. This is done to correct misalignment issues that may cause pain and discomfort.
Misaligned vertebrae often result in excessive painful movement along the spinal cord along with posture and balance complications. When spinal fusion is done, stability is improved along the spinal cord (along with pain relief).
A laminectomy is the most common procedure used to treat excessive bone growth along the spinal cord. A surgeon will typically remove excessive bone tissue that may be exerting pressure on your spinal nerves.
Because a laminectomy often results in a less stable spine, the procedure may also be accompanied by spinal fusion.
A common cause of back pain is compressed nerves along your spine. During a foraminotomy, your surgeon will cut away bone tissue that is exerting undue pressure on your nerve endings. This will create extra space for your nerves to relax and to experience less pain.
Most back surgery procedures do result in less pain than there initially was. For example, spinal fusion typically results in a 50% reduction in pain levels. And when accompanied by a healthy and active lifestyle, back pain can eventually go away on a permanent basis. Therefore, back surgery can be an essential starting point for long-term pain relief and a healthier back.
If your insurance company declines a claim for back surgery coverage, they may be preventing you access to long-term pain relief from back issues. This is why it’s important to follow up your initial claim with an appeal (if the initial claim was denied).
Health Complications That May Warrant Back Surgery
Are you a good candidate for back surgery? There is currently a raging debate involving the need and effectiveness of various back surgery procedures. Many people worry about the invasiveness, side effects, and recovery time that comes with back surgery. Other patients wonder whether alternative treatment options may be more effective and reliable for them.
If you’ve tried various conservative treatment options for back pain- such as medication and physical therapy- and they’ve yielded only limited results, back surgery may be a good option for you to consider. This is particularly true if you frequently endure consistent and disabling pain, which may also spread to other areas of the body (such as the arms and legs).
You should consider back surgery if you experience any of the following conditions.
- A herniated disc
If your doctor determines you have a disc that has slipped out of place, surgery may be necessary to remove or reposition this misplaced disc. A herniated disc often causes frequent pain originating from the back and radiating towards your legs, hands, and arms. Such pain may also affect bowel control and interfere with your daily life activities.
A herniated disc can be surgically removed and replaced with an implant to stabilize the affected region.
- A narrow spinal canal
A fractured bone, arthritis, or excessive bone density can also cause the spinal canal to become narrow. Surgical procedures such as spinal fusion can be used to remove excessive bone tissue and to fuse your vertebrae together for added stability.
- A tumor
Though less common, you may have a tumor along the back that is compressing the nerves and causing pain (along with mobility issues). Such a tumor may need to be surgically removed to protect the nerves and the entire spinal cord.
- You don’t wish to take lots of pain medication
For patients who are affected by (or who don’t wish to take) pain medication, back surgery may provide a longer-term solution for back issues. Rather than taking daily pills for pain relief, surgery addresses the main issue causing such pain. In this way, patients will suffer from fewer back pain symptoms without enduring the side effects of various pills.
Even more encouraging is that many back surgery procedures are less invasive than they were before. Doctors only need to make minimal incisions to get to the affected site. They also use advanced equipment (such as micro-cameras and accurate surgical instruments) that cause minimal loss of blood and little damage to your muscles, nerves and other tissues. As a result, you can enjoy quicker recovery times and fewer side effects.
Back Surgery and Medical Insurance
If you and your doctor have decided that back surgery is the best treatment option for you, the next step is to determine how you can pay for it. As you probably know, back surgery is expensive. Luckily, health insurance can cover a significant portion of the cost of the procedure if you qualify for coverage. It’s important to understand if you qualify for such coverage, so you don’t have to incur hefty out of pocket expenses.
As a general rule of thumb, medical insurance will cover back surgery if it’s deemed to be medically necessary. Back surgery costs include more than just the cost of the procedure itself. The final bill also includes the following:
- Any necessary medications that you may need to take prior to the procedure
- Medical tests such as MRIs, blood tests, and bone tissue tests
- Recovery and rehabilitation
When filing a claim for back surgery coverage, the most important step is to communicate with your health insurance company. This involves filling out all the necessary paperwork and including important details that surround your medical procedure. During a typical insurance claim, expect the following to happen:
- Your doctor recommends back surgery based on your current condition
- All the necessary paperwork is filled out and submitted to your insurance company
- Your insurer grants pre-approval for the surgery
- The surgical procedure is carried out
- Your insurer covers their portion of the bill, leaving any deductibles for you to cover.
Health Insurance Denial for Back Surgery
All is not so rosy when it comes to back surgery coverage. There are many instances where coverage may be denied because of various underlying reasons. For example, a health insurer may deny you coverage if they determine that your policy has surgical restrictions, the procedure is not medically necessary, or you’ve exceeded the limit of your coverage.
Denial may also occur if your doctor is not within the insurer’s network of approved health care providers.
How to Appeal an Insurance Denial for Back Surgery
When you are denied coverage for back surgery, you may feel stuck with no way out. Luckily, all insurance companies in the country are required to provide an appeals process for coverage denial. This appeals process gives patients a second chance to justify the necessity of the procedure they’re looking to undertake. While each company will have a unique appeals process, the overall flow is generally the same.
Appeals typically occur in 3 stages/levels.
A level 1 appeal is reviewed by a special committee put in place by the insurance company. A medical director may also be responsible for reviewing the appeal and making a second decision.
A medical director of the insurance company will make a level 2 appeals decision. The director will typically not be involved in the initial decision-making process, thus providing a fresh perspective to the patient’s application process.
During a level 3 appeal, the final decision is made by a 3rdparty, independent reviewer. The reviewer will work in collaboration with a board-certified physician who is in the same field/specialty as your doctor.
Having understood the three levels of appeals, you can work with a law firm and your doctor to prepare a strong application that will have the initial decision reviewed.
Once you receive a denial letter, you should begin by carefully reading the reason why your claim was denied. Many denials occur merely because you didn’t provide enough information. Work with your doctor to gather all the necessary documents regarding the procedure you need to undertake and resubmit the claim.
Your initial claim for coverage may also be denied due to confusion by the insurer, or due to a determination that the procedure is not medically necessary. In such cases, you should prepare an appeal that justifies the medical necessity of your claim. The appeal should also clearly explain what your procedure involves and how it will help with your current back or spinal complications.
As you prepare an appeal, keep the following factors in mind.
- Work closely with your doctor
In most cases, your doctor will have experience in appealing a decision made by your health insurer. You should work closely with them to prepare a strong appeal. They also have enough medical knowledge regarding your specific procedure, and they’re best suited to provide any necessary information. Some may even contact the insurer on your behalf, thus making the appeals process easier.
- Have a clear understanding of the appeals process
While the general appeals process occurs as mentioned above, each insurer will have their unique variation. Make sure you clearly understand how appeals occur, the necessary timelines, and the documentation you will need to provide.
- Be prepared to provide enough evidence
Many back surgery procedures are viewed as being elective and not medically necessary. The key to having an appeal accepted is providing as much information and evidence as possible. This starts with you and how your current back issues are affecting your quality of life.
In addition to medical evidence, consider drafting a personal letter to your insurer detailing how your back condition is limiting both your personal and professional activities. By humanizing your situation, the insurer will relate more closely to your condition.
Back Surgery Insurance Denial Lawyer Near Me
Taking on an insurance company by yourself can be quite intimidating. While you may have sufficient medical grounds for coverage, the appeals process may seem overwhelming to most patients. That is why you should consider seeking legal representation for a denied claim.
Dealing with frequent back pain and other related issues could hold you back in your daily life. Luckily, a medical insurance denial law firm can help you prepare a strong appeal in your favor. When filing a claim, the law firm coordinates efforts between the insurance company, you, and your doctor. And because they have plenty of experience in handling medical coverage denials, you can receive the advice necessary to ensure that your procedure is covered by insurance.