[Bill33]

Hey everyone! I am a 33 yo male with severe arthritis of the spine. Neurologist diagnosis: "Severe disk space collapse L5S1 w/central disk bulge and black degenerative disk L4-5 w/annulat rear."

My 1st visit to the neurologist he looked at my MRI and stated my L5 disk is basically gone. He stated that physical therapy would be a waste of time, i'm in great physical shape, aside from back issue.

I went for a cortisone(epidural) shot the next week, same Dr. I cont'd working and my bending and twisting of the waist began to produce even more pain. I contacted my neurosurgeon to inquire on more invasive procedures, since my disk is gone. I figured the cortisone is a temp relief, but the pain was still there.

Basically, I can move normally about my waist, until the pain worsens and I start to experience severe back muscle spasms.

The neurosurgeon submitted a pre-cert to my ins co Anthem bcbs...he requested approval for a Lumbar laminectomy and lumbar fusion PLIF L4-5, L5S1..

Anthem's response was "not medically necessary"and MRI doesn't support surgeon's claim of cause of pain. So, we appealed 1st level w/Discogram with another neurologist.

Results: Severely degenerative, severely painful L4-5 intervertebral disc which produced concordant low back and bilateral hip pain @ very low intradiscal pressurization(1.0 cc injected w/opening pressure of 17 psi/max 35psi...the pain was reported @23 PSI. nucleogram demonstrated posterocentral annular rent(Type V disc).

L5-S1: couldn't be cannulated utilizing the transpendicular approach due to severe posterior disc space collapse.

L2-3, severely degenerative, pain free
L3-4, normal appearing pain free.

The discogram was the test that my neurosurgeon said would show the problems clearly...it did, that was the 1st level appeal documentation sent.

Anthem bcbs denies appeal stating: The patient(member) has severe arthritis in the spine, but the medical literature shows that these surgeries are NOT likely to make the pain better. The member doesn't have other problems such as spinal stenosis, narrowing of spinal column, or an unstable spine.

Anthem then states, furthermore, a positive discogram is a poor indicator of a good result from a lumbar fusion surgery. A recent study found only a 27% success from spinal fusion for my case, vs a 72% success rate in patients having a well-accepted single-level lumbar pathology of unstable spondylolisthesis. (Carragee, 2006)

That's my to date situation. I'm appealing 2nd level w/2nd opinion from another neurosurgeon...Anthem has stated that a 2nd opinion won't reverse denial since it's an arthritis issue. My MAIN concern is the L5S1 collapse, as my spine is bone to bone w/S1.