Prior Auth Denied for Back Surgery. Currently Appealing & Spiraling.

Good evening,

Stats to help: 31/F/34203/$150K combined/BCBSMA (Spouse’s Employer Insurance)

I have been suffering from low back pain consistently since 2009, had monthly flares and PCP prescribed muscle relaxers to get by every so often. Then I got into a car wreck in 2018 that ended up making it worse (couldn’t walk/lift/bend). The pain was so awful, I had to leave any job involving standing and walking and now I work from home.

After going through a total of 3 orthopedic surgeons, 3 chiropractors, 3 physical therapy facilities, and 2 personal trainers which no long-term improvement, I found an orthopedic surgeon earlier this year to discuss Artificial Disc Replacement surgery. We scheduled the procedure for 12/07 and BCBS denied authorization on surgery day.

Medical policy states the device as “investigational” and the denial states “it lacks sound scientific research which shows its long-term benefit and improvement compared to other surgical treatments”.

I immediately started the appeal the same day as the denial and my surgeon is scheduling a peer-to-peer review either today or tomorrow.

I even contacted the medical device company for help; I was referred to this patient advocacy company called MCRA, who told me they can step in if the peer to peer review gets denied and IF my surgeon signs off on it.

Since the denial, I was able to collect 90% of my medical history for my back from almost all old providers. (The last one has the worst customer service possible and won’t even call me back, considering legal intervention)

I want to know if there is anything else I can do to help overturn this appeal?

I have been extremely focused on getting all documentation and calling offices for updates. This is now all I think about day in and day out and I am losing even more sleep besides back pain. This is also aggravating my already established psychological conditions. I already can’t move much around my house, so I refresh patient portals, send new questions to the appeals department, re-write my appeal letter again and again, and go over my charts to make sure everything is organized.

I don’t know what else to do and who to talk to about it, could use a little guidance.