Los Angeles Back Surgery Denial Lawyer

Whether your back issues are the result of a catastrophic accident, the culmination of a lifetime of manual labor, or the result of years of steadily weakening joints or ligaments, it is vital to receive the care necessary to make your life more comfortable. Unfortunately, the back surgery that may be necessary to improve these conditions can be very expensive. Many people are subscribers of health insurance plans that are supposed to provide payments to doctors and hospitals for these treatments. However, getting the insurance companies to approve these procedures can be difficult. A Los Angeles back surgery denial lawyer can help you obtain the care you need to improve the quality of your life. A vigilant health insurance denial attorney could demand that insurance companies honor their agreements and file necessary appeals and lawsuits to get you the care you need.

Which Back Problems Might Warrant Intervention Including Spinal Surgery?

It is estimated that more than 65 million people in the United States suffer from chronic back pain. Suffering from chronic, debilitating pain can have a huge impact on day-to-day life, including the ability to work. In addition to physical pain, chronic back pain can impact mood, relationships, and even memory. Perhaps you have seen a doctor for your chronic back pain and have found that your insurer requires step therapy. Step therapy involves starting with less expensive therapies like steroid injections or regular physical therapy before the insurer will pay for a potentially pain-relieving surgical procedure.  Some of the more common back issues that could require surgical intervention or other types of newer procedures include:

• Spinal Stenosis is a narrowing of the spinal column that places excessive pressure on the spinal cord and surrounding nerves.
• Bulging discs and herniated discs—discs are cushions between the bones that form the spine and have an outer layer of tough cartilage surrounding softer cartilage in the center. Over time discs show wear and tear and become less flexible. These changes can cause the outer layer of the disc to bulge out (bulging disc) or cause a crack in the tough outer layer of cartilage (herniated disc). While both issues are painful, a herniated disc is more likely to cause serious, chronic pain, as the cartilage sticking out can irritate nerve roots.
• Spondylolisthesis occurs when one or more bones in the spine have slipped out of place. Spondylolisthesis can happen anywhere along the spine but is most common in the lower back.
• Degenerative disc disease causes damage to the spinal discs as a result of aging and normal wear and tear.
• Vertebral fractures occur when either osteoporosis or spinal injuries cause bones along the spine to break.
• Scoliosis is an abnormal S-shaped or C-shaped sideways curve of the spine, often diagnosed in children and teens.
• Cervical disc herniation causes pain in the neck and arms, while lumbar disc herniation causes pain or lumbar disc herniation causes pain in the lower back and legs.
• Sciatica is caused by a lumbar disc herniation that causes shooting pain down the leg or foot, numbness, and leg tingling.
• Compression fractures from trauma or osteoporosis can cause vertebral collapse, leading to pain and sometimes causing deformities and loss of height.
• Cauda Equina Syndrome occurs when there is a central disc herniation that causes loss of motor or bladder control. This issue usually requires immediate surgical intervention.

“Traditional” Spinal Surgeries and Back Pain Procedures That Could Receive a Spinal Surgery Insurance Denial

It can be devastating—especially if your back issue has caused you chronic pain and other adverse symptoms—to find that your insurance company is refusing to pay for a procedure your doctor feels will help relieve your suffering. A spinal surgery insurance denial requires immediate legal assistance from a highly skilled spinal procedures insurance denial attorney like Scott Glovsky Some of the surgeries and procedures that could potentially be denied even though they are well-documented and are not considered “experimental” or “investigational,” include:

• When spinal stenosis causes a narrowing of the spinal canal, resulting in weakness, chronic pain, and numbness, a spinal laminectomy or spinal decompression may be used to relieve the patient’s suffering. During a spinal laminectomy, a surgeon removes the bony walls of the vertebrae, along with any visible bone spurs, to open up the spinal column and remove nerve pressure. As a non-surgical option, spinal decompression involves using a traction table to gently stretch the spine.
• When osteoporosis causes compression fractures of the vertebrae, a doctor may recommend vertebroplasty or kyphoplasty. Vertebroplasty involves injecting special cement into a cracked or broken spinal bone to help relieve the pain of a compression fracture. Kyphoplasty also involves the injection of a special cement into the vertebra while also creating space for the treatment with a balloon-like device, meant to restore the normal height of a damaged vertebra. In both procedures, the glue-like bone cement hardens, strengthening the bone.
• To prevent bulging discs that are thickened with age from pressing on the surrounding nerves, a surgeon may perform a The surgeon will make an incision on the patient’s back or neck, exposing the affected vertebra, and then will surgically widen the area, or remove any blockages that could be causing the pain.
• Sometimes known as plasma disc decompression, nucleoplasty involves the use of radiofrequency energy to treat mildly herniated discs that are causing lower back pain. A needle is inserted into the disc, then a plasma laser device is inserted into the needle. The top of the needle is then heated, effectively “vaporizing” the disc tissue, reducing the size and relieving the pressure on the nerves.
• When a herniated disc is pressing on the spinal cord or surrounding nerves, a surgeon may perform a This surgery removes the damaged part of the disc that has the soft center pushing through the tough outer lining and pressing on nearby nerves. In many cases, a laminectomy and discectomy are performed together.
• Spinal fusion involves a surgeon entering the body through the back, fusing the sacroiliac bone to the ilium and sacrum. A bone graft may encourage bone growth, making a single, immobile unit. A surgery and implant known as iFuse was approved by the FDA in 2009 and has been performed over 45,000 times.
• As a potential alternative to spinal fusion, artificial disc replacement involves removing the disc and replacing it with a synthetic disc that assists in restoring height and movement between the vertebrae while reducing chronic pain.

If your doctor has recommended one of the above surgeries for your chronic back pain, yet you have received a spinal surgery insurance denial from your insurance company, you may feel discouraged. This is the time to speak to a knowledgeable, experienced insurance denial attorney who can help you get the treatment you need.

Newer Spine Procedures That Could Face Spinal Procedures Insurance Denial

In addition to the more traditional back surgeries that are usually—but not always—approved by insurance companies, there are newer spinal procedures that potentially offer more benefits but may receive a spinal surgery insurance denial. These procedures include:

• Prodisc-C disc replacement and Synthes ProDisc-C Cervical Disc replacement—Prodisc-C is comprised of three components—two cobalt chrome alloy endplates and an ultra-high molecular weight polyethylene inlay. The implant is a ball and socket design with a fixed center of rotation and may be used in the spinal column, or the cervical (neck) region of the spinal column.
• LDR Mobi-C cervical discs are superior to disc fusion for two-level disc replacement. The Mobi-C is an artificial disc, designed to maintain neck motion. Mobi-C is a proven technique with ten years of clinical data showing improved outcomes for one and two-level replacements.
• Lumbar disc replacement from Centinel Spine is the most studied total disc replacement system in the world with more than 540 clinical studies backing the procedure.
• Endoscopic lumbar fusion and bi-portal endoscopic spine surgery are minimally invasive spinal surgeries that implement a “floating” technique, using endoscopic or arthroscopic instruments. These techniques allow for reduced dissection and muscle injury. Dr. Don Young Park is a Board-Certified orthopedic spine surgeon and a world expert in endoscopic spine surgeries and minimally invasive spine surgeries.
• The TOPS System of Spinal Implants treats spinal stenosis, spondylolisthesis, and other related lower back conditions. The procedure stabilizes the spine, allowing for a normal range of motion without fusing the spinal bones.
• Minimally invasive spinal fusion surgeries include Transforaminal lumbar interbody fusion (MIS-TLIF) which inserts a disc spacer and inserts a pedicle screw from the back through a small skin incision. Nerve decompression can also be done during MIS-TLIF. Oblique lumbar interbody fusion (OLIF) and extreme lateral lumbar interbody fusion (XLIF) are done in the same manner as MIS-TLIF.
• A computerized 3D navigation system that scans the spine during surgery is known as the O-arm navigation system. This system creates spinal images in both 2D and 3D, allowing the surgeon to see every angle of the spine in real-time, increasing accuracy and safety.
• A tool that evaluates the function of nerves and spinal cord during surgery is known as intra-operative neuromonitoring. This tool requires specialized experts to interpret the results and is often used in high-risk surgery to correct spinal deformities such as scoliosis.

If your doctor has recommended one of the above spinal procedures and you received a spinal procedure insurance denial, the Law Offices of Scott Glovsky is here to help you get the treatment you need and deserve.

Spine Procedures Often Denied by Anthem Blue Cross and Others

While any health insurance company can deny spine procedures, deeming them “not medically necessary,” “experimental,” or “investigational,” Anthem Blue Cross is known to deny the following procedures (and other health insurance companies may do the same).

• Percutaneous and Endoscopic Spinal Surgery
• Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• Epiduroscopy
• Axial Lumbar Interbody Fusion
• Interspinous Process Fixation Devices
• Intervertebral Stabilization Devices
• Implanted Devices for Spinal Stenosis

While Anthem covers Mobi-C in other states, it may or may not cover the spinal procedure in California. If you find your spine procedure is being denied by your insurer, attorney Scott Glovsky and his legal team can help.

Why Would an Insurance Company Deny a Back Surgery?

Health insurance operates on the premise that the insurance company will pay for any medically necessary treatment that is likely to improve a person’s quality of life. However, insurance companies do not always believe back surgery is a necessary treatment since many procedures are not guaranteed to result in success. Issues such as sciatica, bulging disks, or back fractures can continue to impact a person’s life even after a successful procedure. Because of this, policyholders may need to appeal the denial by demonstrating that their doctors give their condition a solid chance of improvement.

Insurance companies may also deny a claim based upon a perceived lack of truthfulness of their subscribers. Whenever someone applies for health insurance coverage, they are required by law to provide accurate information concerning their current health. If the insurance company believes that the insured did not disclose a prior back condition when applying for the plan, the insurer may deny payment for that condition or rescind the policy entirely.

Options for Appealing Denied Back Surgery Claims

The most direct way to seek enforcement of a policy may be to file an appeal with the insurance company. Under California law, all companies are required to maintain an internal appeals process to handle client disputes. Insurance companies must give policyholders at least 30 days after the receipt of a denial letter to file the appeal.

If this appeal fails to resolve the issue, the individual may either take their case to the State or initiate a civil lawsuit depending on the circumstances. The State handles all matters of health insurance claims disputes through the Department of Managed Healthcare (DMHC). The DMHC is an agency that employs an independent board of doctors who examine health insurance denials and issue rulings determining whether the insurance company should pay for the proposed treatment.

If a person chooses to file an appeal with the DMHC and receives an unfavorable decision, they may still take their case to court. Insurance policies are a contract between the insurance company and the insured. If the insurance company refuses to honor its end of the bargain by not paying for covered treatment, the subscriber may be able to ask that the court enforce the contract. A Los Angeles back surgery denial lawyer could help an individual file an appeal for a denied claim.

How a Los Angeles Back Surgery Denial Attorney Can Be an Advocate

A successful back surgery can relieve years of pain and give people a new lease on life. However, these procedures can be very expensive and health insurance companies may hesitate to pay for them, claiming that it is a luxury that has no medical necessity. Health insurers may also attempt to argue that the procedure is not guaranteed to fix the core problem.

A Los Angeles back surgery denial lawyer can help. An attorney with years of experience in filing appeals with both insurance companies and the State demanding enforcement of insurance policies can fight for you to receive the coverage you may be entitled to. Call today to discuss your case.

The Law Offices of Scott Glovsky

The Law Offices of Scott Glovsky focuses on health insurance law. We have represented injured consumers and victims of wrongful business practices for more than the past two decades. Scott Glovsky is recognized as one California’s most experienced, compassionate, and trusted insurance law attorneys.