Not resolved

Denial for a spinal fusion twice. Exhausted all my appeals.

Have also exhausted all conservative treatment with no relief. Was told by BCBS I don't have spinal instability even though three doctors say I need the surgery. Have undergone pain management, facet-joint injections, epidural shots, physical therapy, etc. My most recent lawyer told me it's hard to win a case vs.

ERISA type insurances so he dropped the case. I don't know what to do. Now BCBS is not covering my drug tests to keep my medication going because it's considered lab work.

I have to do this every month to keep my meds. A night mare!

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San Antonio, Texas, United States #727879

It sounds like you don't actually have BCBS insurance, but rather that your employer (or spouse's employer) is self-insured and uses BCBS to administer their plan. This means that while you deal with BCBS and BCBS makes the approvals/denial choices that they're actually only doing so per the rules the employer has set.

It means instead of having BCBS insurance you in truth (assuming the employer is called XYZ Inc) have XYZ Inc Insurance administered by BCBS. This means that you need to request your employer provide an override to BCBS that they will pay for the surgery. Also your lawyer was correct, companies that self-insure like this just using BCBS to administer their plan have lots of legal protection, including they don't have to comply with state law insurance mandates.

PS I find most people in this situation have no clue that their employer is actually self-insured since all they see is a card that says BCBS or Humana, or etc...

masking the fact that that company is only administering your employers self-insurance plan, and not actually providing the company insurance.


We too are fighting with BCBS of Oklahoma on a 360 fusion for my wife. We are fighting as hard as we can, but it's like they are catagorically denying this type of surgery for everyone. It's as if they would rather promote the long term use of narcotics to facilitate an addiction, as well as see hard working people who have paid for their insurance for many years lose their jobs, house everything!!!

We're still fighting and will continue to fight for as long as we can before having to move to a homeless shelter.

Good Luck!!

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