Due to changes in the criteria and guidelines used for determining insurance approval for various spine procedures, especially lumbar fusions, rejections are increasingly common. Steps can be taken to appeal an insurance denial in an effort to secure approval for your procedure.
Work with Your Surgeon and PCP
More spine surgeons are getting involved with efforts to help reverse initial denials. Since your primary care physician is likely to have been the doctor you first saw about your issue, he or she should also be involved with the process, at least as far as providing supporting documentation. Ask your surgeon to speak with the medical director with your insurance provider directly to explain the need for your procedure.
Take Advantage of a Newer Appeals Process
Under the terms of the Affordable Care Act, all insurance providers must have some type of appeals process in place for instances when coverage is denied. If you need some help with the process, consider working with an attorney specializing in medical claims. Common reasons for the denial of spine procedures include:
- Clerical errors with codes required for specific procedures
- Lack of evidence you’ve tried non-surgical spine treatments without success
- Insufficient documentation indicating a valid reason for the procedure
See If Your Case Fits within NASS Guidelines
The North American Spine Society (NASS) provides guidelines for spine procedures widely accepted within the medical community. Ask your surgeon if your case fits within these guidelines. If it does, it may be easier to make a compelling reason for your insurance provider to reconsider their coverage denial.
Establish a Professional Rapport with Your Contacts
If the contact people at your insurance provider see you as more than just another case, they may be more inclined to work with you. Remain professional and calm when calling or emailing since it’s likely your case will be taken seriously with this approach.
Surgeons are taking steps to adapt to changes within the insurance industry by accumulating more patient data. It’s a step you can take yourself by making a list of what your insurance provider is requesting and working with your doctor and spine surgeon in Santa Monica to gather the requested documentation.
For more information or a second opinion, call The Spine Institute Center for Spinal Restoration at (310) 828-7757 and schedule an in-person consultation with Dr. Hyun Bae, the center’s medical director, a leader in minimally invasive surgery and motion preserving technologies.