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Does Denial of Coverage Ever Happen for the Right Reasons?

Over the weekend I came across an article about Blue Cross and Blue Shield of North Carolina being the first large insurance company to refuse to pay for spinal fusion operations for back trouble. I had my usual grumble in my coffee about insurers deciding what medical care is appropriate for whom and then I started reading a little more about the procedure in question.

It’s intended to ease lower back pain, but apparently is no more effective than considerably less aggressive tactics. There’s also, according to the Wall Street Journal, a rather nasty amount of money being paid out by the maker of the hardware involved, Medtronic, and surgeons who are performing the procedure. According to Medicare, the cost of spinal fusions has risen from $343 million in 1997 to $2.24 billion in 2008.

Blue Cross is particularly refusing to pay for the procedure in patients who have degenerative disk disease because there’s no evidence that the fusion helps them in any way. So why would a surgeon recommend it? Ask the guy who received $13 million in royalty and consulting payments from a medical device manufacturer in the first three quarters of 2010 alone.

I am in no way a fan of insurers deciding what treatment a person does and does not need, but in this case, they may have a point. It also speaks to a point I come back to over and over again, the need for vigilance on the part of the individual. If your doctor recommends a procedure and your insurer denies it, look at the procedure itself as well as the behavior of your insurance company. Is it controversial? If so, why? And if it’s controversial, why is your physician recommending it? Does he have a financial connection with a device manufacturer or drug company?

Yes, people. Doctors have conflicts of interest. Big. Expensive. Conflicts of interests. The one person you can really count on to protect you is you.

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