Charlotte fell one day while walking to her car, landing painfully on her side on a concrete curb divider. The back pain that followed did not go away. In fact, it began to crescendo into sciatic radiation down the left leg along the side of the calf and into the foot. After a month of suffering with this pain, she came to the clinic.
Her physical exam revealed exquisite tenderness over the middle to lower lumbar spine such that I could not palpate the muscles deeply. There were significant muscle spasms in the lumbar spine. Movement was difficult with much guarding when trying to walk. The orthopedic and neurological exam showed evidence that she was getting significant pressure on the fifth lumbar nerve.
I x-rayed her lumbar spine to find evidence of two lumbar fractures at L4 and L5, the two lowest lumbar vertebrae. Both of these fractures were spondylolistheses, specific types of fractures in which the vertebrae break on both sides and separate into two pieces. In light of the recent trauma history (the fall), the fact that there were two adjacent vertebrae affected, and the new onset of sciatic pain, the standard of care demanded urgent imaging via MRI to assess her injury further.
By the way, "standard of care" in this usage is tied to the answer to a simple question: "What would a reasonable practitioner do in this situation, given the facts at hand?" I know of no one who would not order an MRI under these circumstances. In fact, the law under which I practice requires it.
The MRI request, clinical data, and insurance information were sent to the imaging center nearby via fax. The attached information underscored the urgent nature of the scan because there was a good chance Charlotte would need a surgical consultation. Then we waited for the imaging center staff to obtain pre-certification of the MRI with the insurance company. One of the many reasons I like to use this imaging center is that they take so much of the strain off the patient by dealing with the insurance issues.
The pre-certification did not come. In fact, it was, incredibly, denied days later by the insurance company for "lack of medical necessity," despite all the documentation of the injury.
I got a fax from the insurance company later that requested more information. I put the clinical data on the form, explaining in large block letters that this was an emergency situation--a post-trauma MRI on someone with evidence of spinal fractures and spinal nerve pressure. Again it was denied after another delay of several days.
I called the insurance company and waited until I got an actual homo sapiens on the phone. "Is it your practice to deny MRI services to your insureds who suffer fractures?" I asked, trying to show patience and restraint, although I was livid on Charlotte's behalf by now. The question got me transferred to a supervisor. When I repeated my question, I was transferred again for a "peer-to-peer" discussion with Dr. Matthews, whose credentials were never divulged.
I explained the situation to Dr. Matthews (again), then repeated my question. He finally said he might get it approved, but I would have to get a radiologist to read my films. This is not only a professional slap, but represents a ridiculous extra layer of wasted time and expense--all while Charlotte was trying to keep her job, working with a fractured spine.
I went to the radiologist and got the over-read as demanded which restated my findings. The radiologist and I both faxed the report to Dr. Matthews. A week later, we were still denied. Another phone call revealed that Dr. Matthews denied getting the fax--so apparently both faxes failed (?) inexplicably.
Three weeks went by before the insurance company agreed to cover the emergency MRI for Charlotte, which did confirm fracture with stenosis at the level of the L5 nerve on the left side.
When Charlotte finally got the "emergency MRI" via her insurance, the policy shifted a large part of the cost back to her. Here is the added insult: Charlotte discovered that it would have cost her less had she paid cash for the MRI and abandoned her insurance coverage three weeks earlier. That's right. Her MRI was more expensive to her with insurance coverage than if she'd paid cash outright. And they wasted three weeks. And Charlotte has a broken spine.
What we take from this story is that Charlotte's insurance company states they cover services, but in fact, she pays for the service and the premium as well. Thus, her insurance benefits are truly an illusion. This is an insidious and malignant form of fraud, and it is rampant in the insurance industry today.
The good news is that we got her to an excellent orthopedist who will see her emergently. He knows this insurance company well, so he was not surprised. This "scan scam" is just business as usual.