Many physicians and patients look to surgery as a way to correct conditions of the spine in order to find pain relief and increase mobility. It is not always as easy as simply scheduling a surgery time, though; the insurance company generally needs to pre-certify the procedure before it is performed, and certain criteria must be met before approval is given.
An insurance policy is a contract between the insurance provider and the consumer, and each policy should clearly define what types of procedures are covered and to what extent. Some spinal surgeries may not be approved unless the patient has certain diagnosis. For example, a company may approve surgical spinal decompression for a diagnosis of sciatica, but may refuse payment for the procedure for a diagnosis of general back pain. Also, the coverage may only be approved after other, less-invasive treatments have been attempted and have failed.
The surgeon who is to perform the surgery will most often need to be included in the insurance company’s network of providers, and the hospital or surgery center where the procedure is to be performed generally needs to be part of the network. Coverage for spinal surgery may be denied if the patient has already reached their maximum lifetime limit of coverage. Before pre-approving spine surgery, the insurance company may make a determination whether or not the procedure is medically necessary.
The Appeals Process
If an insurance company denies coverage for a specific procedure, the patient can start an appeals process in an effort to overturn the decision. Each company has a specific protocol that patients need to follow when making an appeal, and the process typically is comprised of three steps involving the company’s appeals staff, the medical director and a third party review board.
For other questions about insurance and spine surgery procedures, reach out to The Spine Institute Center for Spinal Restoration in Santa Monica, CA. Our team of world-class spinal surgeons work with a number of insurance companies and our experienced staff can help you find out if you are part of the network. Learn more about insurance for spine surgery by calling us today at 310-828-7757 and schedule an in-person consultation.