Patients say coverage of spine fusion surgery harder to get after BCBS of Kansas policy change

By: Jason Tarr Email
By: Jason Tarr Email

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BROOKVILLE, Kan. -- Each step Brookville's Pamela Lindquist takes, reminds the 37-year-old mother of two of the excruciating back pain she says she must survive every day.

"It affects everything, it's in my hips, it goes into my legs," Lindquist said.

She says simple actions like walking to the car are nearly unbearable and require assistance from her family members.

"It's humiliating to have to ask for help to do menial things like putting on your socks and pulling up your pants," Lindquist said.

She says there's a surgery that could help take the pain away. It's a surgery that three of her insurance company's in-network doctors say she needs.

But it's a surgery she says she can't get coverage for from Blue Cross and Blue Shield of Kansas, despite her appeals. She's already received two denial letters.

Without coverage of the surgery by her insurance company, she says there is no way her family can afford the more than $100,000 procedure.

"I'm angry. I'm hurt. I feel abandoned," Lindquist said.

At least two other people with severe back pain have contacted KAKE News to say they too have been denied coverage of Lumbar Spine Fusion Surgery since the company made a policy change on July 8th of last year.

Lindquist has connected with them using social media.

"There are so many of us that are swept into this group now and it's hard to see that light at the end of the tunnel right now," Lindquist said.

Mary Beth Chambers, Manager of Corporate Communications for Blue Cross and Blue Shield of Kansas, says the policy change was made in light of a body of research done in the last 10 years.

She says the research overwhelmingly shows spine fusion surgery is dangerous and often isn't necessary.

"Because of the overuse and (given) sometimes spinal fusion surgery is actually counterproductive to a patient, we want to make sure our members are receiving the quality services they need and are not getting something that's not appropriate for them," Chambers said. "The studies support that non-surgical interventions over a period of time can result in the same benefits as having the surgery."

She says that research, along with new standards of care and input from contracting spine surgeons, caused Blue Cross and Blue Shield of Kansas to look more closely at these kinds of cases. They've also added to the requirements that must be met for coverage of the surgery.

She says other insurance companies across the nation have taken a similar approach.

"I do think there's a trend in the country to take this research and look at what we are doing as a country," Chambers said.

Now, before being approved for lumbar spine fusion surgery, a Blue Cross and Blue Shield of Kansas patient must show documentation that they first tried all other non-surgical options over a period of time, Chambers said.

That documentation may need to include diagnostic scans that show a condition, documentation of an attempt at physical therapy, documentation of the use of prescription-strength anti-inflammatories and documentation that despite doing non-surgical treatments, function impairment and pain have not diminished.

That documentation is now not only reviewed by precertification nurses but also by independent spine surgeons.

"(It's) to make sure that based on his or her expertise that they think the surgery is appropriate," Chambers said.

She says she can't discuss any patient's case specifically because of privacy laws, but says often when coverage is denied it is because of a problem with the necessary documentation.

If the spinal fusion surgery is deemed "not medically necessary" by the precertification nurse and spine fusion expert, there can be a series of appeals, Chambers said.

Chambers says the next step would be a peer-to-peer review in which an expert, often from out-of-state because of a lack of available local experts, will look at a case file and speak with a provider. Should that appeal fail, both the provider and the member have the right to appeal to other external experts through the Kansas Insurance Department, Chambers said.

But Pamela Lindquist and others say they have been through those appeals. They believe they've tried all the non-surgical options and provided all the documentation that is required but they still can't get coverage. They say it's led them to believe Blue Cross and Blue Shield of Kansas is not working in their interest.

They say they would like to see a change because they say their quality of life depends on it.

"I'm not living, I'm existing. I want to live my life with my family again. I want to contribute," Lindquist said. "We are not asking for any special favors. We are asking for what is right."


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