BCBS: "Not medically necessary"

Greetings All,

My health insurance is Anthem BCBS and is "self-funded" by my employer (local government). Last year, I took a nasty spill down our basement steps, and as a result I later learned I have 3 herniated discs in my back. I am in near-constant pain from this.

I wanted an MRI, but I was first forced to go through PT and finally got my primary care doc to push BCBS for the MRI. That is when I learned I had the herniated discs in my (thoracic) mid-back. My primary care doc referred me to pain management. They reviewed and determined the best course of action were 2 injections into my spine to grant some temporary relief and to determine if I was likely to benefit from a nerve ablation.

This is where the trouble w/ BCBS starts. They refused to cover the injections ($600 each) and then later refused to cover the ablation ($1400) by stating it was "not medically necessary". In the denial letter, they said if the location of the herniated discs would have been in either my neck or lower back, they would cover the procedures.

I appealed. They denied the appeal. I then sought an external review. The external review upheld the appeal. To add insult to injury, the denial letter on the appeals said that I could contact the department of commerce and insurance for my state and ask them to intervene, so I did.

The State promptly replied and told me that because my plan is "self-funded" that they do not have jurisdiction, and that I might be able to get help from Federal HHS. I tried them, and they said they couldn't assist here either.

What else can I do, short of suing BCBS? (Can I even do that?) I am very angry, and very frustrated. I fail to see how the location of my injury allows them to claim "not medically necessary treatment.

Thanks in advance for any/all constructive advice or assistance.

submitted by /u/robroy90
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