My 2nd appeal was denied, so I have initiated the 3rd and final appeal. My case is going to an external reviewer for final determination. This reviewer will look at the medical documentation and decided whether or not surgery is necessary. This person is not bound by the guidelines and policies that my insurance company has set in place. If this person (an orthopedic spine surgeon) determines that I do, in fact, need this surgery, then my insurance company MUST pay for it. If this person decides that I do not need surgery, then my insurance does NOT have to pay for it.
I have learned that although my doctor (both original and spine surgeon) have determined that I need surgery, according to my insurance handbook it doesn't meet their guidelines. It doesn't mean that I don't need the surgery - it just means I don't fit in their neat little box that says I do.
I spoke to the gentleman in charge of my external review yesterday. He did get it out the door yesterday afternoon because I asked for it to be expedited. He indicated that the external reviewer has three business days to return an answer to them. He also said he expects to have an answer before the end of the week. So, at the latest, I will have an answer sometime Monday.
I am asking for continued prayers as I struggle through this journey. I have found myself through an emotional roller coaster in the last week. I have struggled with why this would happen to me. I am continuing to struggle with that. I have been hurt, frustrated, angry, and depressed over this situation. I am putting my trust in God, but some days I find that difficult. I know He does what is best for us, I just struggle with the thought that He is wanting me to continue to be in this amount of pain with no alternative other than medication. It doesn't make sense. Someone suggested to me it is what He wants and I don't believe it. I believe there is an outside force fighting with God to interfere with the desired outcome. So, each day I continue to pray for the best.
I lost the first appeal, I lost the second appeal, isn't the saying third times a charm?
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