Blue Cross Denies Back Surgery for Chronic Pain

Even though a medical procedure can be required by a surgeon for a patient’s mobility or chronic pain, that will not meet Blue Cross’ standards of “Medical Necessity.”

WEBWIRE – Wednesday, March 14, 2012

Blue Cross has adopted language in their health insurance policies that limits coverage to procedures it deems “Medically Necessary”. Even though a medical procedure can be required by a surgeon for a patient’s mobility or chronic pain, that will not meet Blue Cross’ standards of “Medical Necessity.”

David Cragg, a 57 year old gentleman with chronic pain and total lack of mobility, was denied coverage by Blue Cross of California for surgery to fix two collapsed discs in his lower back. This condition has reduced his mobility to the point where he is disabled and can no longer walk around the block, exercise, pick up something off the floor or otherwise maintain normal activities. Over the last three months, his condition degenerated to the point that he collapses to the ground or over furniture from his frequent back spasms.

The chronic pain in his back, buttocks and legs finally convinced him to visit Dr Michael Kropf at the Cedars-Sinai Spine Center in Los Angeles. Over the next three visits, the doctor had Mr Cragg have an MRI and Discogram. The MRI confirmed no disc material was left in L5 and the two discs above it had little or no space left between the vertebras. The discogram confirmed that the pain in his legs and buttocks was from the nerve pinch from L5 and the back spasms from nerve damage caused by a herniated disk. Dr Michael Kropt concluded that the only procedure to address the pain and spasms would be spinal fusion.

Even though Dr Kropf felt that a disc fusion was the only procedure that could address the problems, Dr Jesse Weigner and then Dr Maureen Prowse of Blue Cross concluded that based on the Milliman Guidelines, surgery was not medically necessary. According to the Milliman Guidelines, the only justification for spine fusion is when there are signs that the spine bones can slip out of normal position (instability)”. This guideline excludes chronic pain, lack of motion, lack of mobility or any other justification.