Appealing With an IMR

Hi, I have Blueshield PPO and need spinal surgery. I got an issue at the level above an old surgery site and T1 is starting become pretty decently herniated. My Dr. submitted a prior authorization for surgery and insurance denied it because the MRI report says I have mild stenosis so it's not medically necessary according to them. Thing is I have severe symptoms of stenosis, intermittent numbness/tingling down my left arm. This surgery would be a revision, but the neck pain and symptoms are new and getting progressively worse and i've had massive migraines over the last year when before I never had them.

In their final appeal/grievance denial letter blue shield said that my doctor should submit under a different CPT code to get approved but when I talked to my surgeon he said, "there is no other CPT code for this issue." I'm very frustrated & upset by all of this.

I have documentation from the surgeon that did my first surgery saying considering my situation, MRI and the symptoms it's advisable I get surgery to correct this, my current surgeon (I moved states) says I need it and then I have documentation from Kaiser back in 2020 where their surgeon said surgery would be the next steps but I declined back then because it wasn't causing pain the way it is now.

Also I've been disabled/off work per my pain doctor because of the severity of the migraines and I had to scramble to get neck injections, see a neurologist, get botox for the migraines, start physical therapy yet again, etc. etc. to handle all of this. I'm going back to work this week out of pure necessity, but I'm worried I'm not going to be able to last all day with the pain, so that's a whole other mess.

I'm thinking of submitting an IMR with the state to get this done, but I don't want to mess it up. Do you think they'd approve it on the basis that three surgeons independently agree that surgery is the best next steps? Should I seek legal counsel first? Or? Help.

submitted by /u/thefaith1029
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