Tricia's SI Joint Surgery
Donation protected
My Wife has been suffering with chronic back pain since October 2012. We have been through all the normal procedures and have been denied the ONLY next step which has been recommended by at least 3 doctors. The Insurance company believes this to be "experimental" yet, they offer no alternatives.
Here is her continuing battle:
My name is Patricia Owen, and I have been suffering with chronic lower back pain that is directly related to the SI joint on my right side.
In late October 2012, after grocery shopping, my husband was putting the bags into the trunk and I went around to the passenger seat to sit down. As I bent/squatted/leaned over (whatever that motion is to sit in a car) I felt a sharp searing pain in my lower back and screamed. This pain has not stopped since, and seems to be getting progressively worse. I have been seeing a Pain Management Doctor, Adam, and over the last 29 months we have been trying each and every conservative treatment out there to help either fix the issue or decrease the pain as much as possible. This includes 3 fluoroscopic injections directly into the joint, 2 nerve-blocks, 2 trigger point injections, 2 RFAs, 30 Physical Therapy visits (which is the insurance max for the year), chiropractic therapy, dry-needling, acupuncture, and a whole mess of medications. Currently, I am on the strongest medication available. The injections did provide some relief, but it was temporary. Never lasting much longer than a day. Dr. Adam recently discovered that I have joint disease in my right SI Joint and that is why the injections don't help - it all leaks out before it has time to work. Physical Therapy is almost useless, because I am in such a high level of pain all my therapist can do is try to decrease my pain rather than helping me strengthen my core, etc.
After the last RFA was unsuccessful, Dr. Adam sent me to Dr. Anthony. He gave me a thorough physical exam, and determined that the iFuse procedure would benefit me greatly. We began the process of obtaining a pre-authorization from my insurance (Blue Cross Blue Shield of North Carolina, Blue Options 1-2-3), and was declined. Dr. Anthonty requested a peer-to-peer review which was also declined, citing that "Sacroiliac joint fusion surgery is considered investigational for the treatment of mechanical low back pain when the sacroiliac joint is the suspected cause." And when it is considered investigational it is deemed NOT MEDICALLY NECESSARY.
http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/sacroiliac_joint_fusion.pdf
. At this point, i initiated an appeal, which has recently been declined. According to BCBS company policy, they will not cover this iFuse procedure if I do not have one of the following:
"Sacroiliac joint fusion procedures may be considered medically necessary for any of the following indications:
• as an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum; or
• as an adjunct to the medical treatment of sacroiliac joint infection/sepsis; or
• severe traumatic injuries associated with pelvic ring fracture; or
• when multisegment spinal constructs extend to the sacrum/ilium, for covered lumbar spine fusion procedures (See medical policy, ‘Lumbar Spine Fusion Surgery’). "
I do not have a specific traumatic event that happened, however, after reading their policy, I have fallen down stairs, sprained ankles, etc more times than I can count. As a general rule, I always seem to land on my rear-end. Especially with falling down stairs. When speaking with doctors I always just cited the grocery store trip because that is when the pain started. How am I supposed to know that falls months ago were the cause? How is it when the SI Joint is the suspected cause of this awful pain somehow deem it NOT medically necessary? Why does it matter?
Last September, I switched Insurance and Surgeons. This new Surgeon, Dr. Alfred listened carefully to my story and performed a thorough physical exam. He looked at all my imaging and previous patient records - all of which are clean. "The cleanest MRI I've ever seen," as he put it. After analyzing everything, he said that I was a textbook case for this surgery. So that's now 4 doctors/therapists that are all saying the same thing: I've done all the conservative treatments to no avail, this surgery is my only hope for a normal life.
I need help in trying to persuade these insurance people to clear me for surgery. I am in extreme pain all of the time. I am drugged 24/7and I am barely holding on to my job because of all this. It is so hard to push through every day dealing with this pain and trying to remain functional. My life right now is that I go to work when i can, and then i come home, eat dinner, and head to bed. The bed is the only place that is comfortable. I cannot stand more than a couple of minutes before the pain elevates from a deep ache to a searing pain at the SI Joint area. I have a hard time showering as that requires me to stand for 10-15 minutes which is something i just cannot do. There are a lot of days where I have to exit the shower, go lay down in bed, and then get back in the shower to finish whatever I didn't get done in the first round. I cant pick up and hold my friends children. I cant drive sometimes when it is real bad. This affects my right side, which is my driving leg. Start/Stop traffic is excruciating. There are days where I feel like just giving up. To stop pushing myself and just go on disability. I am rapidly falling down the rabbit hole of depression. I just got married a few years back and 2013 was the year we had planned to start a family. We have had to put that on hold, obviously. I cannot be pregnant while taking all these drugs and I cannot get through the day without the drugs.
I am, on average, functioning at 9/10 on the pain scale. That is NO exaggeration. The pain starts at the SI Joint location on my right side, radiates out to my hip and around and down through the lower abdomen to my vaginal area, and down my right leg. It is a combination of a deep ache and a searing hot almost debilitating pain. There is no comfortable spot. I haven't had a good nights rest in I don't know how long. My left side is starting to bother me some, but its at random times and is never constant like my right side is. Cold weather, Rainy weather make it ten times worse. And my monthly time is just miserable. Pain skyrockets to levels I have never experienced before. My 10/10 keeps reaching new heights. Over these last 29 months this pain has never improved much, but it has DEFINITELY gotten worse and worse as time goes on.
The drugs make me normal. I never feel "high." There are occasions where the drugs don't even seem to work. I never leave the house without my heating pad and my drugs. I have had to politely decline most of the social activity in these past 13 months. My husband and I even had to cancel Christmas plans with our families at our house because of my condition. I can't cook, I can't host, I can barely be a warm human at this point.
I am exhausted. I am in pain. I am tired of being moody. I am tired of crying all the time (and at work, which is just super Professional). I just want this over with. I can't think of anything more medically necessary than fixing the source of chronic pain that has affected their life in such a dramatic way. Why wouldn't they want to fix the source so that they would not have to pay for the constant doctor visits and steady flow of various medications?
My second appeal was denied at which point I reached out to see if there is anything the SI-Bone organization can do to help me. They did their best and when I was told the procedure is now billable, we shook hands and they moved on to the next case. I was told, by a BCBS CSR that I was all set. Nothing to worry about. There was some paperwork required but the info for the paperwork would be culled during/after surgery.
Minutes before leaving for the hospital for some pre-op stuff - TWO DAYS prior to surgery, I was notified that my surgery has been denied. They said that the information my Surgeon's office sent did NOT proved medical neccessity, thus it being denied. I don't know what world these people live in, but it is completely obvious in my records that this IS MY ONLY HOPE. I've done everything else, everything!
I cannot go on any longer like this. My husband And so decided that we would self pay, and figure it out later. We have no idea how we are going to pay this hospital bill, but I need this to be over. My poor dear, patient, caring husband needs this to be over.
I want my life back. I NEED my life back. This is no life, living like this. Please help me.
More information about the surgery she needs http://si-bone.com/patients/ifuse-implant-system/
http://si-bone.com/patients/ifuse-implant-system/
Here is her continuing battle:
My name is Patricia Owen, and I have been suffering with chronic lower back pain that is directly related to the SI joint on my right side.
In late October 2012, after grocery shopping, my husband was putting the bags into the trunk and I went around to the passenger seat to sit down. As I bent/squatted/leaned over (whatever that motion is to sit in a car) I felt a sharp searing pain in my lower back and screamed. This pain has not stopped since, and seems to be getting progressively worse. I have been seeing a Pain Management Doctor, Adam, and over the last 29 months we have been trying each and every conservative treatment out there to help either fix the issue or decrease the pain as much as possible. This includes 3 fluoroscopic injections directly into the joint, 2 nerve-blocks, 2 trigger point injections, 2 RFAs, 30 Physical Therapy visits (which is the insurance max for the year), chiropractic therapy, dry-needling, acupuncture, and a whole mess of medications. Currently, I am on the strongest medication available. The injections did provide some relief, but it was temporary. Never lasting much longer than a day. Dr. Adam recently discovered that I have joint disease in my right SI Joint and that is why the injections don't help - it all leaks out before it has time to work. Physical Therapy is almost useless, because I am in such a high level of pain all my therapist can do is try to decrease my pain rather than helping me strengthen my core, etc.
After the last RFA was unsuccessful, Dr. Adam sent me to Dr. Anthony. He gave me a thorough physical exam, and determined that the iFuse procedure would benefit me greatly. We began the process of obtaining a pre-authorization from my insurance (Blue Cross Blue Shield of North Carolina, Blue Options 1-2-3), and was declined. Dr. Anthonty requested a peer-to-peer review which was also declined, citing that "Sacroiliac joint fusion surgery is considered investigational for the treatment of mechanical low back pain when the sacroiliac joint is the suspected cause." And when it is considered investigational it is deemed NOT MEDICALLY NECESSARY.
http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/sacroiliac_joint_fusion.pdf
. At this point, i initiated an appeal, which has recently been declined. According to BCBS company policy, they will not cover this iFuse procedure if I do not have one of the following:
"Sacroiliac joint fusion procedures may be considered medically necessary for any of the following indications:
• as an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum; or
• as an adjunct to the medical treatment of sacroiliac joint infection/sepsis; or
• severe traumatic injuries associated with pelvic ring fracture; or
• when multisegment spinal constructs extend to the sacrum/ilium, for covered lumbar spine fusion procedures (See medical policy, ‘Lumbar Spine Fusion Surgery’). "
I do not have a specific traumatic event that happened, however, after reading their policy, I have fallen down stairs, sprained ankles, etc more times than I can count. As a general rule, I always seem to land on my rear-end. Especially with falling down stairs. When speaking with doctors I always just cited the grocery store trip because that is when the pain started. How am I supposed to know that falls months ago were the cause? How is it when the SI Joint is the suspected cause of this awful pain somehow deem it NOT medically necessary? Why does it matter?
Last September, I switched Insurance and Surgeons. This new Surgeon, Dr. Alfred listened carefully to my story and performed a thorough physical exam. He looked at all my imaging and previous patient records - all of which are clean. "The cleanest MRI I've ever seen," as he put it. After analyzing everything, he said that I was a textbook case for this surgery. So that's now 4 doctors/therapists that are all saying the same thing: I've done all the conservative treatments to no avail, this surgery is my only hope for a normal life.
I need help in trying to persuade these insurance people to clear me for surgery. I am in extreme pain all of the time. I am drugged 24/7and I am barely holding on to my job because of all this. It is so hard to push through every day dealing with this pain and trying to remain functional. My life right now is that I go to work when i can, and then i come home, eat dinner, and head to bed. The bed is the only place that is comfortable. I cannot stand more than a couple of minutes before the pain elevates from a deep ache to a searing pain at the SI Joint area. I have a hard time showering as that requires me to stand for 10-15 minutes which is something i just cannot do. There are a lot of days where I have to exit the shower, go lay down in bed, and then get back in the shower to finish whatever I didn't get done in the first round. I cant pick up and hold my friends children. I cant drive sometimes when it is real bad. This affects my right side, which is my driving leg. Start/Stop traffic is excruciating. There are days where I feel like just giving up. To stop pushing myself and just go on disability. I am rapidly falling down the rabbit hole of depression. I just got married a few years back and 2013 was the year we had planned to start a family. We have had to put that on hold, obviously. I cannot be pregnant while taking all these drugs and I cannot get through the day without the drugs.
I am, on average, functioning at 9/10 on the pain scale. That is NO exaggeration. The pain starts at the SI Joint location on my right side, radiates out to my hip and around and down through the lower abdomen to my vaginal area, and down my right leg. It is a combination of a deep ache and a searing hot almost debilitating pain. There is no comfortable spot. I haven't had a good nights rest in I don't know how long. My left side is starting to bother me some, but its at random times and is never constant like my right side is. Cold weather, Rainy weather make it ten times worse. And my monthly time is just miserable. Pain skyrockets to levels I have never experienced before. My 10/10 keeps reaching new heights. Over these last 29 months this pain has never improved much, but it has DEFINITELY gotten worse and worse as time goes on.
The drugs make me normal. I never feel "high." There are occasions where the drugs don't even seem to work. I never leave the house without my heating pad and my drugs. I have had to politely decline most of the social activity in these past 13 months. My husband and I even had to cancel Christmas plans with our families at our house because of my condition. I can't cook, I can't host, I can barely be a warm human at this point.
I am exhausted. I am in pain. I am tired of being moody. I am tired of crying all the time (and at work, which is just super Professional). I just want this over with. I can't think of anything more medically necessary than fixing the source of chronic pain that has affected their life in such a dramatic way. Why wouldn't they want to fix the source so that they would not have to pay for the constant doctor visits and steady flow of various medications?
My second appeal was denied at which point I reached out to see if there is anything the SI-Bone organization can do to help me. They did their best and when I was told the procedure is now billable, we shook hands and they moved on to the next case. I was told, by a BCBS CSR that I was all set. Nothing to worry about. There was some paperwork required but the info for the paperwork would be culled during/after surgery.
Minutes before leaving for the hospital for some pre-op stuff - TWO DAYS prior to surgery, I was notified that my surgery has been denied. They said that the information my Surgeon's office sent did NOT proved medical neccessity, thus it being denied. I don't know what world these people live in, but it is completely obvious in my records that this IS MY ONLY HOPE. I've done everything else, everything!
I cannot go on any longer like this. My husband And so decided that we would self pay, and figure it out later. We have no idea how we are going to pay this hospital bill, but I need this to be over. My poor dear, patient, caring husband needs this to be over.
I want my life back. I NEED my life back. This is no life, living like this. Please help me.
More information about the surgery she needs http://si-bone.com/patients/ifuse-implant-system/
http://si-bone.com/patients/ifuse-implant-system/
Organizer
Brad Owen
Organizer
Waxhaw, NC
