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Thread: Cervical stenosis and insurance/hospital dispute

  1. #1

    Cervical stenosis and insurance/hospital dispute

    My mom has been diagnosed with cervical stenosis (in her neck). She was diagnosed back in May 2007, after an MRI was done because she complained of numbness on the right side of her body and a "pins and needles" sensation throughout her body. We were told by her neurosurgeon that it is quite severe and needs to be operated on.

    Her surgery was approved by her HMO, but herein lies the problem. The surgery itself was approved, but the implants to fuse the bones and provide stabilization were not.

    So far, she has been sitting in the hospital for over a week and absolutely nothing has been done for her. Her neurosurgeon#1 was planning to do the surgery but has been told by the hospital admin that they will not let the surgery take place with the cost of the implants uncovered. They got a 2nd opinion from neurosurgeon#2 (the only other neurosurgeon in her network) and they actually instructed neurosurgeon #1 to discharge my mother. Keep in mind, the 2nd neurosurgeon never even looked at her MRI when he made his decision. The neurosurgeon#1 disagreed with their stance and felt it was unethical to discharge my mother knowing that she has this problem. He told them that if they wanted to discharge her, they needed to take his name off as her doctor and put neurosurgeon #2 on as her doctor.

    So right now, my mother is still sitting in the hospital without anything being done. Neurosurgeon#1 has been taken off her case, and another doctor (not the 2nd neurosurgeon) has been placed as her doctor. I'm not sure if there's something peculiar going on but it sure seems like neurosurgeon#2 is trying to avoid any legal liability for my mother.

    I have since spoken to neurosurgeon#2 to get an idea for what he is planning to do as far as surgery for my mother. He said that he still plans to do surgery, only differently from what was originally planned. Instead of fixing 3 of the discs, he thinks that 1 will do. And instead of fusion, he wants to do a laminaplasty. Again, keep in mind, he said all this after he just glanced at the MRIs from my mother's bedside. Neurosurgeon#1 had only returned them to her the day before and this was the first time neurosurgeon#2 even saw them.

    From an overview, this case has been highly problematic at the hospital. My mom's case has been taken over by the Director of case management at the hospital. She said that the case was becoming so problematic that she felt it was necessary for her to personally oversee it. She came in to ask me a series of questions, emphasizing a lot on trying to establish this case as a preexisting condition.

    Right now, I'm trying to get her transferred to another hospital in her network because that's what neurosurgeon#1 recommended. I am not happy with the care my mom's received at this hospital especially since I found out that neurosurgeon#2 has a bad reputation for being manipulated by the hospital (this was through talking to the nurses staffed there).

    I don't really know what to do, I don't know what my mom's rights are and I feel that there are a lot of measures taken by the hospital to avoid legal liability.

    If you have any suggestions for me, that'd be so helpful. Fyi, She has Blue Cross HMO.

  2. #2
    Forgot to mention as well, my mother just turned 47 (she spent her birthday in the hospital, crying). And I am 22.

  3. #3
    Senior Member
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    Take your mother to a hospital and a doctor within her plan. I would not let doctor # whatever operate on my mother.
    T12-L2; Burst fracture L1: Incomplete walking with AFO's and cane since 1989

    My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

  4. #4
    File an appeal. All HMOs have an appeal process. This can be done for the implants as well as for the surgeon. You can request an out-of-network referral or even hospitalization this way. You also have the right to request that the appeal be reviewed by a non-network neurosurgeon expert. Don't give in. People are paralyzed daily not only from spinal stenosis, but from the surgery to correct it (even when done by the best surgeons). I would never accept 2nd best for my mother.

    You may even need to go to the newspaper if you don't get any action. Lots of papers love stories on mean HMOs, esp. as they can get good tie-in with the release of "Sicko" in local theaters.

    (KLD)

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