Troubleshooter: Surgeries denied

May 2, 2011 2:40:26 PM PDT
William Shearin has lived with severe back pain for 15 years.

"I don't have a life and my family don't have a life because we can't do anything," he explained.

Shearin can't work, can't travel, and can only walk for a few minutes before he has to sit down.

"It's made me just a homebody," he said.

Todd Slater feels his pain. The teacher and coach told ABC11 he feels disabled at only 30 years old.

"The leg pain and the constant back pain, bending down hurts, sitting down hurts, nothing is comfortable, Slater explained.

Both men have endured physical therapy and back injections for degenerative disk disease.

"We have tried all options. The only thing I'm doing now is taking medications," said Shearin

Both men are popping pain pills daily, and both say they thought they had no other option until their doctor told them about spinal fusion surgery.

"He said the good news is I can do the surgery, the bad news is your insurance company, insurance carrier won't pay for it," said Slater

The men say Blue Cross and Blue Shield of North Carolina told them it wouldn't cover the cost of spinal fusion surgery.

The company first started denying coverage for the procedure this year.

"They've decided to limit or exclude the patients care before any real medical discussion can take place," offered Dr. William Lestini with the Triangle Spine and Back Care Center.

The clinic treats both men and says the new Blue Cross policy is a disservice to patients.

"This really interferes with the doctor patient relationship because essentially Blue Cross has already determined a patient's care," said Lestini.

Lestini told ABC11 he thinks it's about profits over patients.

"I think it's on their radar because the procedure has become more effective, more popular, it's expensive, and they're trying to limit their costs," he explained.

And Lestini says Blue Cross will still have to pay for a lifetime worth of chronic drug treatment.

"Their policy basically says that you treat them basically with medications, narcotic pain medications, physical therapy, which they've all had anyway. And then if there's problems with that, if you have problems with the medication or addiction, that they will treat the cognitive behavioral or addiction problems as they arise. That's the end game for these people," he said.

But Blue Cross and Blue Shield of NC told ABC11 the company doesn't see it that way.

"We really want what's best for our members and our patients," offered Dr. Andy Bonin.

Bonin, a medical director with Blue Cross, admits they used to cover the surgery for this condition up until this year, but says after looking at the scientific evidence, the complications, and the costs associated with spinal fusion surgery, they decided to make this change.

"It's very expensive surgery, but we feel our policies really are helping the patients and protecting the patients that might not be the best choice of surgery for their particular condition. We want our members to have the right procedure the right surgery for the right condition," said Bonin. "If, in that process, you avoid the surgery that wasn't the best surgery for you, and you avoid the potential complications, then I think you've done a lot more than save money."

Dr. Bonin points out spinal fusion surgery is an elective surgery, and while they do cover the surgery for 11 other conditions, when it comes to treating degenerative disk disease, he says there are other alternatives.

"This doesn't close the door on all surgeries. Remember, this is fusion versus decompression surgery. When decompression surgery is enough, when the scientific evidence shows adding a fusion to decompression does no better, why go through the extra risk, the extra evasion of a fusion surgery?" said Bonin.

Lestini rejects that argument

"I feel badly for the Blue Cross patients here because Blue Cross has really interjected a desperate level of care. I don't go into a room where I see a patient and think about their insurance. I tell them what I think medically they need," he said.

Shearin and Slater appealed Blue Cross's decision to deny coverage and were once again denied.

They both can file another appeal for a review to be done by an independent provider not associated with Blue Cross and Blue Shield of North Carolina.

"There's nothing I can do, be on narcotics for the rest of my life and that's not something I want to do," said Slater

"I'm just hoping they'll change their mind and look at the people instead of looking at their pocket books," said Shearin.

Denial of coverage for this specific back surgery could just be the beginning. Dr. Bonin told ABC11 that Blue Cross is currently reviewing many conditions, prescriptions, and procedures.

Classifieds | Report A Typo |  Send Tip |  Get Alerts | See Click Fix
Follow @abc11 on Twitter  |  Become a fan on Facebook

Load Comments