Florida Blue Denies Approved Spine Surgery After Delay

Patient's Spine Surgery Denial

• 💡 A woman in Lutz, Florida, received a denial letter for spine surgery from Florida Blue after it had been previously approved.
• 📌 The insurance company stated the surgery was "experimental or investigational," despite an earlier authorization.

Circumstances of the Injury

• 🤕 The patient, Sherry Kelly, suffered a severe neck and back injury after tripping on parts of a disassembled golf cart during a walk.
• ⚠️ Months of pain and ineffective chiropractic treatment and medication led her to consult a neurosurgeon.

Medical Recommendation and Initial Approval

• 🏥 A board-certified neurosurgeon recommended a series of four procedures, estimated at $150,000, to address her condition.
• ✅ The initial authorization for all four procedures was approved on February 25th, after being submitted on February 12th.

Surgery Delay and Re-authorization Issues

• 💔 Sherry had to postpone the surgery scheduled in Maine due to her father's funeral in April, as she is the executor of his estate.
• 🔄 Upon her return, her doctor submitted another authorization, but Florida Blue denied it, citing it as experimental and investigational.
• ⏳ A physician noted that pre-authorizations are typically valid for about 30 days, suggesting the re-authorization process led to a different outcome.

Appeal Process and Independent Review

• 📉 Sherry appealed the denial twice, receiving a second denial each time.
• 🧐 Her case was sent to Dane Street, an independent medical review company selected by Florida Blue, for review.
• ⚠️ The doctor reviewing her case was an internist, not a specialist in neurosurgery, and was trained in Jordan, raising concerns about the review's impartiality and expertise.

Current Status and Patient's Feelings

• 🩹 Florida Blue later approved a claim for surgery on her most damaged disc after being contacted by the investigative team, though Sherry believes this only addresses part of the problem.
• 😥 Sherry expressed feeling exhausted by the prolonged process and the prospect of multiple surgeries instead of one comprehensive procedure.