Anyone a back surgeon or ortho surgeon?

I have x-ray image but am unable to upload. Forum broken. Can email or text if needed.

 

My girlfriend (age 28) fell down the steps approx 3 weeks ago. She suffered a compression fracture of her T8 vertebrae. They said approx 50% deformation. Giving it time to see if it will heal has not helped. Pain has increased. Vertebroplasty was one option but due to her age (28) they were weary of the long term since that is usually performed on older and less mobile patients. She was sent to a specialist (Dr Oalan in DC) and scheduled for a KIVA VCF procedure. According to specialist she is perfect candidate for this and should recover most if not all of the 50% compression and be back to normal very quickly.

 

Surgery was scheduled for yesterday. They cancelled Wed afternoon due to insurance denial. After some calls she was told the specialists office hadn't submitted all required notes and paperwork. If submitted they would likely cover the procedure. Today she called insurance (blue cross blue shield) and the specialists office sent the notes but entered the procedure codes as being for back pain not for a compression fracture. They have now denied the surgery due to that error. They said she needs to be over 40 years old and have osteoporosis to be eligible for the KIVA procedure or the Vertebroplasty according to the guidelines for authorization. Basically told her to live with it

 

-It there ANY way to get this worked out with insurance and covered?

 

-She is in severe pain and now her job is in jeopardy due to her not being very mobile due to the pain. She's a single mother just trying to raise her son and not be a statistic who ends up on disability. Her quality of life will be severely damaged if this doesn't get fixed

 

-I obviously cannot afford to pay for the procedure and she can't either

 

Is there anything we can do to get her fixed?

 

Please reply or PM me if you can offer any help or advice.

i know more about this topic than i ever wanted to.

 

 

however my knowledge of thoracic vertebrae injuries is limited.

 

 

Once your opened up for any back operation, life will never be the same.

 

 

best of luck,

 

eric

I worked in health insurance for a while. If the CPT codes were submitted wrong then they need to be re-submitted... that is not enough grounds to deny a claim.

 

She may need to ask BCBS for a "benefits exception". On paper she may not have coverage but sometimes you can make a case, medically, to have it covered. It's likely they will want to exhaust any other (cheaper) alternatives. Your doctor will need to write a letter as to why she needs the procedure.

 

If she looses her job or has low enough income she may qualify for a state or county subsidized plan. In my experience, the coverage on those plans is even better than the private plans. She could also try to shop on the open market but she will need a special enrollment reason (loss of job, move out of state, birth of a child, divorce, etc). Or she will have to wait until open enrollment for 2016.

 

Go check out BCBS' website, find the type of policy she has, find the FULL contract, and then search for the procedure she needs. There may be a process listed to get the coverage she needs. If her plan is not available on their site, have them send you the full plan docs.

 

Do not schedule any surgery until you have written confirmation of coverage.

Thanks guys.

 

I'll definitely check into the benefits exemption.

Ive seen many, many compression fractures that function completely normal after the injury heals, Although the bone is abnormal now, its still hard and will heal in its current shape. Vertebroplasty or not, the area will have arthritis later on.

 

It should hurt at this point, as the bone is smashed. Surgery will not speed anything up or take pain away (although some people wake up and feel like they are cured, as they are morphine).

 

The only problem is if she is osteoporotic , and I bet shes not. The cement may only help in this case. The only other wild card is if they see a fragment that could damage a nerve.

 

Im not her doctor, and I cant give any advice. I wouldnt be calling about benefits, as I would not be having surgery at this point. I would be icing, taking pain meds, and anti-inflammatories.

 

 

 

Ive seen many, many compression fractures that function completely normal after the injury heals, Although the bone is abnormal now, its still hard and will heal in its current shape. Vertebroplasty or not, the area will have arthritis later on.

 

It should hurt at this point, as the bone is smashed. Surgery will not speed anything up or take pain away (although some people wake up and feel like they are cured, as they are morphine).

 

The only problem is if she is osteoporotic , and I bet shes not. The cement may only help in this case. The only other wild card is if they see a fragment that could damage a nerve.

 

Im not her doctor, and I cant give any advice. I wouldnt be calling about benefits, as I would not be having surgery at this point. I would be icing, taking pain meds, and anti-inflammatories.

 

The specialist told her with the KIVA procedure she would feel immediate relief from the pain. Also said if not treated she would be hunched over permanently

Make sure that both the specialists performing the procedure, AND the anesthetist, AND the facility are in network. I just had a buddy go through surgery and the first 2 were in network but they ended up rescheduling the surgery for another facility and it turned out the place was out of network.

 

= extra $35,000 charge.

 

The specialist told her with the KIVA procedure she would feel immediate relief from the pain. Also said if not treated she would be hunched over permanently

 

I would get a few opinions, unless there is an emergency that threatens her....not just pain.

 

Ive seen people sneeze and have back surgery. Ive seen doctors make patients mad because they turned down a surgery.

 

Some doctors are conservative, and some will use the scare tactic to accomplish what they want.

 

Other than medication, I see no way to have immediate pain relief when you smash a bone, get cut open, and then put a foreign body in.

 

Long term postural problems? Possibly. Dis-ability, paralysis, death? Possibly.

 

People look at statistics and even when they are low, like one in a million, they think they are going to be that one.

 

When I hear things like this, I try to get people to look at statistics and not get emotional. Some people do, and some dont. Some get better and some die. Im not an expert and am not giving advice. I think she is certain that she wants the surgery. The only people who can probably get this done is the doctor who knows the condition and the insurance specialist who should know the coding. If that does not work, there is a reason for it. Its not justified. I hope that helps!

Sorry to hear about your GF. I have nothing to add other than if you are anywhere near NY, The ONLY hospital I would go to is The Hospital for Special Surgery. I hope everything works out.

Sorry to hear about your Girlfriend. If there's a few things I can tell you, being a Navy Corpsman and treating many patients with a myriad of injuries, the first would be: don't attempt to upload her X-rays here. This is a public forum and unless you both signed a written agreement that you can share her stuff with whomever you like and she's okay with that or whatever, great, but it's still HIPAA and you could potentially have an issue if things go south with you two down the road, (not saying it will, but I would definitely not share someone's X-rays over the internet).

 

Secondly, I'm not sure how many doctors there are here, but some might be hesitant to give any advice regarding a condition to someone who is not their patient, although the thread is mostly insurance related. Everything in the medical field is about liability and you have to be VERY careful about what you say or do because of the weight that it carries. Any back injury is potentially dangerous and can possibly cause further issues with other parts of the body. I don't want to give many details, but you get the idea.

 

I don't have any advice for the insurance portion other than to keep trying.

 

 

 

I have x-ray image but am unable to upload. Forum broken. Can email or text if needed.

 

My girlfriend (age 28) fell down the steps approx 3 weeks ago. She suffered a compression fracture of her T8 vertebrae. They said approx 50% deformation. Giving it time to see if it will heal has not helped. Pain has increased. Vertebroplasty was one option but due to her age (28) they were weary of the long term since that is usually performed on older and less mobile patients. She was sent to a specialist (Dr Oalan in DC) and scheduled for a KIVA VCF procedure. According to specialist she is perfect candidate for this and should recover most if not all of the 50% compression and be back to normal very quickly.

 

Surgery was scheduled for yesterday. They cancelled Wed afternoon due to insurance denial. After some calls she was told the specialists office hadn't submitted all required notes and paperwork. If submitted they would likely cover the procedure. Today she called insurance (blue cross blue shield) and the specialists office sent the notes but entered the procedure codes as being for back pain not for a compression fracture. They have now denied the surgery due to that error. They said she needs to be over 40 years old and have osteoporosis to be eligible for the KIVA procedure or the Vertebroplasty according to the guidelines for authorization. Basically told her to live with it

 

-It there ANY way to get this worked out with insurance and covered?

 

-She is in severe pain and now her job is in jeopardy due to her not being very mobile due to the pain. She's a single mother just trying to raise her son and not be a statistic who ends up on disability. Her quality of life will be severely damaged if this doesn't get fixed

 

-I obviously cannot afford to pay for the procedure and she can't either

 

Is there anything we can do to get her fixed?

 

Please reply or PM me if you can offer any help or advice.

 

I would get a few opinions, unless there is an emergency that threatens her....not just pain.

 

Ive seen people sneeze and have back surgery. Ive seen doctors make patients mad because they turned down a surgery.

 

Some doctors are conservative, and some will use the scare tactic to accomplish what they want.

 

Other than medication, I see no way to have immediate pain relief when you smash a bone, get cut open, and then put a foreign body in.

 

Long term postural problems? Possibly. Dis-ability, paralysis, death? Possibly.

 

People look at statistics and even when they are low, like one in a million, they think they are going to be that one.

 

When I hear things like this, I try to get people to look at statistics and not get emotional. Some people do, and some dont. Some get better and some die. Im not an expert and am not giving advice. I think she is certain that she wants the surgery. The only people who can probably get this done is the doctor who knows the condition and the insurance specialist who should know the coding. If that does not work, there is a reason for it. Its not justified. I hope that helps!

 

The vertebra is shaped like this now <=] instead of like this [=]

Im not a doc but I know thats not good. Thats why there are going to be posture problems

 

Sorry to hear about your Girlfriend. If there's a few things I can tell you, being a Navy Corpsman and treating many patients with a myriad of injuries, the first would be: don't attempt to upload her X-rays here. This is a public forum and unless you both signed a written agreement that you can share her stuff with whomever you like and she's okay with that or whatever, great, but it's still HIPAA and you could potentially have an issue if things go south with you two down the road, (not saying it will, but I would definitely not share someone's X-rays over the internet).

 

Secondly, I'm not sure how many doctors there are here, but some might be hesitant to give any advice regarding a condition to someone who is not their patient, although the thread is mostly insurance related. Everything in the medical field is about liability and you have to be VERY careful about what you say or do because of the weight that it carries. Any back injury is potentially dangerous and can possibly cause further issues with other parts of the body. I don't want to give many details, but you get the idea.

 

I don't have any advice for the insurance portion other than to keep trying.

 

Point taken. I understand the doc comment too. Not looking for a diagnosis more just looking for advice and guidance. There is approx 6 weeks from the injury to have it fixed is what we have been told by 2 different docs. 6 weeks is rapidly approaching. I'm a huge believer of no surgery unless necessary but from what we've been told thats a bad idea to just let it go

 

Also please don't take any of my replies as argumentative. I'm just going based on what I've been told and my own research

Slightly unrelated but I had knee surgery in October to help fix Osgood Schlatters in one knee. Surgery was done by a well respected doctor in the area who made it seem like it was no problem to fix. How definition of fix and mine were apparently not the same. The bump is barely smaller and I still feel some pain and it actually severed some nerves cause I have no feeling on part of it now. That being said, I definitely understand Boner's comments.

Make sure that both the specialists performing the procedure, AND the anesthetist, AND the facility are in network. I just had a buddy go through surgery and the first 2 were in network but they ended up rescheduling the surgery for another facility and it turned out the place was out of network.

 

= extra $35,000 charge.

 

 

in Germany i had 5 operations, the most expensive was $17,000 usd, that included 5 nights in the clinic for post surgery recovery.

 

 

everytime i went for a operation, my hotel bill was higher than ALL the doctor bills combined.

 

 

$35,000 extra LOL and people wonder why i'm leaving america,

Secondly, I'm not sure how many doctors there are here, but some might be hesitant to give any advice regarding a condition to someone who is not their patient, although the thread is mostly insurance related. Everything in the medical field is about liability and you have to be VERY careful about what you say or do because of the weight that it carries. Any back injury is potentially dangerous and can possibly cause further issues with other parts of the body. I don't want to give many details, but you get the idea.

 

I don't have any advice for the insurance portion other than to keep trying.

 

 

 

another strike against the doctors in america, they are so scared of everything nothing gets done,

another strike against the doctors in america, they are so scared of everything nothing gets done,

 

What?? How is that the fault of the medical professional? Why exactly are doctors so scared? Because the mentality fairly unique to America is that we have the right to pursue legal recourse for anything and everything. Blame the legal system and the litiginous society we live in, not the physicians.

What?? How is that the fault of the medical professional? Why exactly are doctors so scared? Because the mentality fairly unique to America is that we have the right to pursue legal recourse for anything and everything. Blame the legal system and the litiginous society we live in, not the physicians.

 

Very well said.

What?? How is that the fault of the medical professional? Why exactly are doctors so scared? Because the mentality fairly unique to America is that we have the right to pursue legal recourse for anything and everything. Blame the legal system and the litiginous society we live in, not the physicians.

 

 

People want to sue for the littlest things. It's quite scary if you make any mistakes whatsoever in this field.

 

I agree 100% with your statement, although I don't think Eric was talking poorly about doctors.

I doubt you would get a doctor in any country to say something like the operation is medically necessary. In other words, you won't get a second opinion here. Big liability.

 

I see this as an insurance problem.

 

As much as I hate the Canadian health system, our medical here, might take a few months longer to get treatment, they do however cover everything, except eye exams under 65 years old and dental, unless its an emergency and the dental was performed in a hospital. Other then that, a doctor says its medically necessary its covered. The wait, my Dad had kidney stones, needed to be surgically removed. Took a year and half to get done.

 

I can't see why the doctor isn't helping with the insurance issue more!

I reached out to a member here who is a surgeon and got some great info. I really appreciate it. He was more than willing to help out.

 

Thanks to everyone for the PM's

I reached out to a member here who is a surgeon and got some great info. I really appreciate it. He was more than willing to help out.

 

Thanks to everyone for the PM's

 

That's good news, I wish your partner a very speedy recovery!

I can't see why the doctor isn't helping with the insurance issue more!

 

because you're Canadian and don't understand the first thing about how the shitty insurance companies work in the US.

because you're Canadian and don't understand the first thing about how the shitty insurance companies work in the US.

 

LOL

 

The socialist health care system in Canada leaves a lot to be desired too. I have had patients with cancer who were told to wait 6 to 9 months for surgery. Bottom line is, if you don't have money and get seriously sick, you are fucked anywhere, maybe a little less in Canada but fucked none the less.

Still don't see why a doctors office that deals with insurance all day, can't do more.

 

Our socialized medicine is fucked. But its the wait times that's the screwed part.

 

 

Still don't see why a doctors office that deals with insurance all day, can't do more.

 

Because the insurance company is going to give him a big haircut over his fees . Medicine is business, so why would you go out of your way to get yourself in a position where you will be offered 30 cents on the dollar for your services, I am just using the 30% figure randomly, could be more or less.