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I need spinal fusion surgery and my federal health insurer and office of personnel management are denying it. Do I have a case?

Quantico, VA |

The medical necessity is plain since I can't stand for more than a few minutes and need narcotics to sit in a normal chair at work . I have exhausted conservative treatments without success over a 3 year period . Have 3 neurosurgeons recommending surgery , but Millikan care guide only allows surgery for spinal instability or spinal steno sis ( which I do not have ) . Common sense says removing the offending joint will remove the pain . Do I have a good chance of winning this based on doctor recommendations vs . the Hillman care guide ? What type of lawyer would I need and how would I find a good one ?

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Attorney answers 3

Posted

There are some lawyers who handle denial of care. May not be easy to quickly find. Look for health insurance law attys, or med mal attys. You may have to talk to a few to see if they handle or know someone in the area that does. You can also try insurance bad faith atty.

Good luck.

Posted

In practice insurance companies and / or administrators will deny coverage what they do not have enough facts. Begin by asking your physician to provide more information directly to the individual making the denial, they will often change their position.

If this doesn't work, seek a second opinion and have that physician send his opinion in.

Only after you have exhausted these less confrontive approaches would I suggest filing a uit.

I am licensed in New Mexico and Pennsylvania, and therefore any discussion of issues related to other states must considered within that context. In addition, my comments are not intended to create a legal representation but merely to respond to the limited facts presented by the question. Any opinion herein is not meant as a precise statement of legal rights or as a recommendation of any particular course of action. A more complete legal review can be obtained through local counsel.

Asker

Posted

Thanks. I have already completed your two suggestions. They are sticking to the Millman Care Guide. In a straightforward case of my doctors against the Millman Guide what chance to I have?

Posted

Is this a federal workers compensation claim, or a private plan?

Seth Carroll is licensed to practice in Virginia only. The preceding is for information only and should not be construed as legal advice. Always call a lawyer directly for advice.

Asker

Posted

Not workers comp, It is my federal employee health plan insurer denying a surgery recommended by 3 neurosurgeons.

Asker

Posted

The surgery has not been done yet.

Seth Raven Carroll

Seth Raven Carroll

Posted

Gotcha, definitely consult with an attorney who specializes in insurance coverage.

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