Debra Voss is in constant pain because of a back problem. She believes she needs an operation. Fortunately, she has health insurance. Unfortunately, the health insurance company won’t pay for the operation.
«I don’t know what to do,» she said.
Voss is 41. She is divorced. She has three children, the youngest of whom is 10. She attended secretarial school after graduating from Bishop DuBourg High School. She has spent most of her working life in the advertising business, most recently as an executive assistant.
The problem with her back began on the Saturday before Christmas.
«My leg started hurting,» – she said. «I’d been on my feet all day, and I thought maybe I had twisted my ankle. Then the pain went into my back. But I wasn’t really worried. The agency I worked for is off between Christmas and New Year’s, so I figured I’d just take it easy and I’d be all right.»
But the pain did not subside. She went to a chiropractor. That did not help. She went to her doctor, who prescribed painkillers and physical therapy. She also ordered an MRI. The MRI revealed degenerative disc disease. At least that is one reading of it. She went to a neurosurgeon. He referred her to a pain specialist who gave her a series of injections. That didn’t help. She had a discogram in which needles were used to probe her discs. That didn’t work. The neurosurgeon then suggested an operation, a lumbar spinal fusion.
This happened over a period of several months. Voss was still working, but she said the situation was becoming unbearable. She was in pain and also groggy from the medication. She said she was nervous about surgery, but she felt she had to do something. She visited another neurosurgeon for a second opinion. She said he agreed that surgery was her best option.
The surgery was scheduled for June at St. Anthony’s Medical Center. She decided to take a leave from work to recuperate. The day before the surgery was scheduled, she got a call from her neurosurgeon’s office. The insurance company had refused to authorize surgery.
The insurance company is Anthem Blue Cross and Blue Shield. It explained the decision to deny surgery in a letter to Voss. “The clinical information provided does not support the medical necessity of Lumbar Spinal Fusion as this procedure is considered not medically necessary as a treatment of low back pain and/or leg pain due to degeneration of lumbar discs unless there is evidence of spondylolisthesis (lack of proper spine alignment) on preoperative X-rays.”
Voss went through the appeal process at Anthem. Her appeals were denied. She has also filed a complaint with the Missouri Department of Insurance.
Her neurosurgeon is Dr. Charles Wetherington. I asked him if other insurance companies approve lumbar spinal fusion when there is no evidence of spondylolisthesis.
«Most do. Some are getting kind of difficult, but generally, if you talk to somebody, they’ll be reasonable,» – he said. In this instance, he spoke with Anthem’s medical director, Dr. Wayne Meyer, but without success.
«We adhere to certain guidelines,» – Meyer said. «They’re clear on this, and they have nothing to do with cost.»
He said the evidence does not show that lumbar spinal fusion is successful or appropriate for most people with lower back pain. «I was in surgical practice myself until two and a half years ago,» – he said. «I still believe in evidence-based medicine.»
I asked about a study that Wetherington referred to from Sweden. «That’s only one study and as I understand it, there are flaws in that study,» – said Meyer.
Meyer also spoke about the appeal process. He said two neurosurgeons from outside the organization reviewed the case and upheld the decision to deny the surgery.
Voss, meanwhile, is beside herself. She has been on unpaid leave from her job since June. «I don’t know what I’m going to do. I can’t work. I’m never comfortable or without pain,» – she said. She said she has nearly exhausted her savings. «I think I might be able to make it though October, but then I don’t know what I’ll do.»
Wetherington said that he performs about 10 of these surgeries a month and he estimated that about a third of them don’t have the conditions that Anthem requires.