Tagged: Pre-approval surgical denials.
DtredwayParticipantMay 20, 2020 at 11:55 pmPost count: 1
Hi. I am currently set to have TLIF surgery next week with you which has currently been denied due to my records showing less than 3 mm movement. My question is considering The effect of having 20 years of Pilates training and practicing, could my ability to mobilize for movement be limiting what the x-ray is showing? I have been suffering for 3 years from initial injury (herniation) which has increased to a large herniation, extrusion and additional bulges at L4 and serious disc degeneration.
I have strength and efficient control to stabilize to allow movement. However after 3 years of continuing to strengthen thru pain, utilizing every non-surgical protocol. Is it possible that when I have been x-rayed that I know how to organize my lower abdominals and deep pelvic muscles before movement to not show the actual slippage. I have always been hyper mobile and struggle with the finding.
Is it possible that if I were to relax, not use my body knowledge and simply relax and bend forward and back for the x-ray, the slippage would be greater by not purposely engaging muscular support and showing more realistic movement. Hence helping my appeal.
Battling this insurance nightmare after believing Hope was possible is very discouraging and I’m looking for what might help keep my surgery on track.
ThanksDonald Corenman, MD, DCModeratorMay 21, 2020 at 7:19 amPost count: 8468
Insurance companies have a convoluted rules system whereby the exact same disorder in one company’s eyes is a surgical repair and the next company will not allow surgery. This denial of surgery is even found with substantial failure of conservative measures and significant impairment of your daily activities. Even between adjusters in the same company (physicians whom have the ability to say yes or no to surgery), opinions can differ.
What this particular insurance company is referring to is “instability” which is a trigger to allow fusion. If a vertebra slips 3mm or more, it is considered unstable and generally, surgery is allowed. Since this is an anonymous site, I can’t identify who you are (and you can’t put an identifier on this site). I can answer your question generally. Yes, some individuals can stabilize their vertebral slip with muscle contraction, preventing the slip from reaching 3mm. I see this all the time when the patient is under anesthesia and a nonexistent or minimal slip becomes much greater (due to the patient being unconscious and unable to engage the “core” muscles).
Now it would be unreasonable to place every patient denied surgery under anesthesia just to prove instability. Also most patients who really do need surgery don’t have instability so that would be a fool’s errand. We simply have to work with the adjuster and appeal this decision unless you can change your insurance company which is no small effort on your part.
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