About Me: The Latest Health Hiccup

Will the injuries never end?

Back in August of this year I experienced a new injury. I still do not know what caused it but in August I was suddenly struck by an immense pain in my left shoulder. I can only describe it as having someone drive a nail through my lower scapula that sent pain radiating out and up into my neck, the top of my shoulder, and down into the upper reaches of my arm. The pain was so severe that I could not move that arm and something as simple as standing up caused me to become nauseated. 

This lasted for the duration of the weekend so first thing Monday morning I was at my primary care physician’s office to discuss the matter with her. My PCP was concerned but hoped that it might be a simple muscle strain caused by overuse or even sleeping on that side wrong. It seemed plausible given my life as a desk jockey and someone who routinely sleeps on my left side (partially because for 6 months I couldn’t sleep on my right side due to an injury in 2020).

My PCP prescribed me some meds to help with the pain and inflammation in addition to giving me an order for physical therapy, the standard treatment for strained muscles and the prerequisite for many health insurance providers before authorizing more expensive tests and/or treatments.

Beginning at the end of August, I attended PT twice a week for 7 weeks. During that time, I was led through a number of exercises by my therapist Jerry. I found the exercises manageable but with pain. Some days were worse than others but I was committed to seeing the process through given that healing usually involves some pain as you work to strengthen or retrain muscles impacted by whatever issue is being addressed. My PT sessions came to an end in early October. I still felt some discomfort and soreness in my shoulder but it wasn’t as constant or severe as it was when the issue started. This led to me be optimistic that the issue was just a simple muscle strain and that my continued exercises at home would led to a full recovery.

Fast forward a few weeks into early November, I am awakened in the middle of the night with the same intense searing pain from August. I’m unable to sleep. I cannot get comfortable in my bed. Any attempt or efforts to move my left arm sends shockwaves of severe pain through my body. As luck would have it, this was also on a Saturday. (Don’t ask me why the bad stuff only happens to me on weekends. I don’t know why but that seems to be when it always strikes!)

As the day progresses, the pain does not subside. It rendered me practically immobile for the entire day. Any movement that jarred, vibrated, bounced, or anything increased the pain. Something as simple as walking to the bathroom or bending over to pick something up off the ground with my right arm caused my left arm to be in absolute agony.

Sunday rolled around with no real improvement to my situation. I contacted my PCP (who I know outside of her medical practice) and explained my situation and concerns. She, without hesitation, suggested a referral to an orthopedic specialist. “You’ve already done PT so if the issue is still occurring then ortho is the next step.” On the next day that her office was open, she sent the appropriate referral to a trusted orthopedic specialist that assisted me with my right shoulder a few years earlier.

Later that same week, I went to see the orthopedic doctor. The drive from my house to his office took roughly an hour. By the time I arrived, my arm was in a state of absolute failure. The steady vibrations that flowed throughout my body over the course of the journey had left my arm all but paralyzed and wracked with pain.

Over the next hour I was subjected to 8 different X-rays. Technically, the X-ray tech was only looking for 3 different poses but technical issues caused me to have to repeat each pose multiple times, each causing me significant pain as rotating and bending that arm was not a pleasant or easy task by that point. And of course, as expected, the X-rays did not show any damage. Neither the ortho doctor nor I thought the issue to be related to bone damage but X-rays, like PT, are a prerequisite for other advanced tests by most health care insurers. The appointment concluded with the ortho doctor suggesting that I get some MRI scans done because he feels the issue could be related to a bulging disc in my spine or some related nerve damage that only an MRI could reveal.

The MRI orders were sent to my preferred imaging location but only after a first set of orders was sent to an imaging provider that I had used previously but was not happy with. I was contacted by the preferred group a few days later to say that they had received the orders from the ortho doctor but would need to get authorization from my insurance provider before any appointment could be scheduled. That call was on Friday, November 22, 2024.

About 10 days later on Monday, December 2, 2024, I received a phone call from a group called Evicore who stated that the authorization request “a recently requested service” had been denied. There was no explanation provided in the automated message about which request was denied, why it was denied, or even if it was my request. For all I knew from the message it could have been a request for one of my kids but logical reasoning would suggest it was my MRI request. It did provide a phone number to call but when I tried to contact that number all I got was another automated recording telling me that Evicore would not tell me more about the case but to contact my doctor’s office. So what’s the point of giving me a phone number to call if there’s nobody to talk to or information to be given? Interestingly enough, later that day I also got a call from the imaging facility that I disliked to say that the authorization had been denied. I received no such call from my preferred facility so I wondered if the authorization for that facility had been denied because the other facility had also sought authorization. It just seemed reasonable that if two groups were seeking authorization for the same service on the same patient that one would be denied while the other was granted, or at least still being considered.

With so little information at hand, I proceeded to call around to try and get some details from my orthopedic doctor’s office. Unfortunately, all I got was voicemail at the doctor’s office. I left a message but did not a get a return call that day to discuss the issue.

The next day (Tuesday, December 3), I called the imaging facility that had initially requested the authorization to see if they had any intel on the matter. Turns out that they did! According to what their records showed, the authorization request was sent back on November 27, 2024, to the ortho doctor’s office with a request for a “peer-to-peer review.” When asked what that was, it was explained to me that the insurer did not feel the initial request contained sufficient information and a peer-to-peer review was an opportunity for the doctor’s office to submit additional information to support the request. And that was the last update that they showed in their system.

Later that day, I get a callback from the ortho’s office in response to my voicemail. I explain what I was told earlier by the polite woman from the imaging location and the person confirmed that they had received the peer-to-peer request on November 27, and that they had submitted the necessary paperwork in response to the request that same day. When I asked about the status of that peer-to-peer review, the lady from the ortho office suggested I contact my health insurance provider for information.

Optimistic that the process was in motion, I held off on contacting anyone else. The imaging office said that the request was last seen in a peer-to-peer state and the ortho office said they had submitted the requested details for that review. To me, it seemed like something which should hash itself out normally over a few days. Unfortunately, a few days passed and nothing had changed. The ortho office did not have any additional data. The imaging facility was still pending an authorization to schedule me for the desired MRIs. It seemed I had no choice but to call my insurance provider to see what the current hold-up was.

On Monday, November 9, 2024, I called the member service number on my insurance card. I spoke to a nice woman named Veronica. I explained the situation and she pulled up the authorization request. Veronica said the request showed denied but she could not find a denial cause. Veronica explained that the authorization had basically been sent to a 3rd party group, the Evicore people who called me on December 2 with an automated message to tell the request had been denied but no other details. Veronica said that if I wanted more information about Evicore’s reason to deny the request that I would need to call them. She provided me with a number for Evicore and we politely parted ways. She was friendly and helpful to the extent she could be but ultimately I left the call in pretty much the same condition as when it started.

After a short breather, I called the number for Evicore that Veronica had provided me. Another polite woman named Suzanne answered. I went through the history of the events and identity verification steps the same as I had with Veronica. Suzanne confirmed that Evicore had denied the request. When I inquired about when the denial was issued, Suzanne said the request was denied on November 28, 2024, less than 24 hours after my orthopedic doctor’s office had submitted the additional case notes that Evicore had requested. Suzanne went on to explain that the denial was issued because the peer-to-peer notes provided by my ortho’s office only mentioned that I had completed physical therapy but did not include the dates that I had received those PT treatments.

This was frustrating to me. Not because the ortho didn’t send those dates but because no effort was made to get them. The PT was ordered by my PCP, not by the ortho. The PT was done at a local PT clinic, not at my ortho. My ortho doctor only knew that I had done PT because I mentioned it during my appointment. At no time did my ortho’s office reach out to me for those dates or to the PT provider for their case notes. Similarly, Evicore had access to my authorization history and claim history, both of which would have given them the dates for the PT services in question but nobody from Evicore bothered to look or to make any level of effort to get that specific set of details from me or any of the related doctor’s/PT’s offices. The information was there but they didn’t feel like putting in the work to find it. If it wasn’t handed to them, it didn’t exist even if they were the ones who paid the bills.

Anyway, after some lengthy conversation with Suzanne to understand the process, I was left with two options. Option A: I track down the case notes from my PT provider, give that information to my ortho’s office, and they file an appeal to the denial. Option B: I wait an additional 45 days and start the process anew, including a new round of PT given that their authorization process requires PT to have been conducted within 60 days of the authorization request and waiting 45 days would put a new request outside of that boundary.

Needless to say, I chose Option A. The notion of sitting around idly for 45 days bearing this pain only to repeat an unsuccessful series of PT sessions before maybe getting to what needs to be done was silly.

After that call was done, I called my ortho’s office to explain to them that the request had been denied and why. I provided them with the necessary information so they could request my medical records from the PT provider, who I had already signed releases with that included the ortho doctor just in case PT wasn’t the solution. Next, I called the PT clinic to see if they could print or email me a copy of my case notes just in case I could get them faster than the ortho’s office. The receptionist there said she would need to look into my request and call me back. About an hour later she called to say that she couldn’t do that for me but instead I would need to contact their associated hospital’s medical records department to request that information. She gave me the phone number that I promptly dialed. I was met with voicemail and left a message with my name, phone number, and exactly what I needed and why.

Keep in mind that all this was done on Monday. The call to my insurance provider. The call to Evicore. The call to my ortho. The call to my PT clinic. The call to their medical records department. All of it was done on Monday, November 9. I spent the better part of the day calling all of these people to find this information because in the course of getting a simple authorization for an MRI scan nobody else could be bothered to do it despite it apparently being vital information.

As luck would have it, the next day (Tuesday) I was in town with our special needs son and near the hospital where the medical records department was located. I still had not received a callback from anyone there since my message the previous day but did not want to squander the opportunity to address the need in person given my close proximity. 

Thankfully, I was able to walk right into their office, fill out a simple form, and have them both fax a copy of my PT records to the ortho’s office while I waited and give me a printed copy that I could take home to scan as a backup. As soon as I was back in my vehicle, I called the ortho’s office to advise them to be on the lookout for that information from that facility in relation to my MRI request and that they needed to include that information in their documentation when filing the authorization appeal. They seemed to understand and I ended the call thinking that things were getting back on track. I still wasn’t sure how a denial fax was sent to the ortho’s office on 11/28 but when I inquired with them several days later they told me the request was pending decision from the peer-to-peer. But hey, whatever. I had already discovered the gap and had taken steps to rectify the situation so there was no point worrying about how that gap was created. It served no value or purpose. I was focused on getting the MRI authorization, not analyzing and criticizing their past office procedures that left me in limbo until I stepped in and took the actions nobody else seemed willing to take.

Once again, I’m thinking things are back on track and the appeal process may take a couple of days. The ortho’s office said they would be on the watch for the notes from my PT sessions and would file the appeal as soon as they received them. There wasn’t much else for me to do at this point but wait and that’s what I did.

I waited until Monday, December 16, 2024. By this time, it had been nearly a week since my case notes had been faxed to my ortho’s office. I even had them confirm to me on the past Wednesday that they had received them the previous day (the Tuesday I had the hospital fax them over). I reached out to my ortho’s office to see if they had an update on the appeal. They said they hadn’t heard anything since faxing the information in for the appeal on Thursday, November 12. That was a bit of a shock to me that they knew this data was needed for an appeal to an authorization request that was 3 weeks old but still waited 48 hours to file the appeal after getting the necessary documentation. I was annoyed but shrugged it off as maybe they were busy and that was the first chance they could get it sent out after getting everything else together and maybe getting the doctor’s signature on anything since he bounces between multiple offices on different days of the week. As our conversation continued, it was again suggested to me by the staff at my ortho’s office to follow-up with my insurance provider for an up-to-date status.

Tuesday the 17th rolled around but I ended up being a bit busier with work that day than expected. As a result, I didn’t get a chance to call anyone before the offices closed for the day. It would have to wait until Wednesday.

Wednesday morning came and as soon as the offices were open I was on the phone. My first call was to Evicore. Since they had issued the denial 20 days prior, I figured they would be the ones the appeal would be filed with. The first Evicore representative I spoke with was a polite man named Ronnie. Ronnie and I discussed the particulars of my situation and he looked into my records to see what he could find. Ronnie confirmed that he saw where my ortho’s office had faxed in some information on 12/12 but was unable to find anything else related to an appeal. Ronnie suggested that I talk with someone in their Physicians Support Department because they deal with denials and may have access to information he doesn’t regarding my case. I agreed to Ronnie’s suggestion and he promptly transferred me to someone in that department.

Enter Monica. Like Ronnie and Suzanne before her, Monica was very friendly and patient with me as I recapped the events leading up to the current call. Monica looked through my case file. And like Ronnie, she sees where information was faxed to Evicore from the ortho’s office on 12/12. But unlike Ronnie, Monica goes on to explain that the appeal was not supposed to be filed with Evicore directly. Per the appeal instructions that were faxed to my doctor’s office with the denial way back on 11/28, the appeal was to be submitted via fax back to my insurance provider at a completely different fax number than the one they used.

But this was not the end of the story. Thankfully, Monica offered to put me on hold while she called my ortho’s office so that she could speak with them about the mixup and provide to them the proper appeal process that they would need use. There was no way for Monica to push the appeal back from Evicore to the insurer. It had to come from the doctor’s office but she very kindly offered to help see that they understood the correct process to take. I thought that was very nice of her to do that for me.

But not to leave it to chance, I also asked Monica to provide me with the appeal instructions. I wanted to contact the ortho office directly to ensure that the information was conveyed to them fully. Plus, if Evicore and I am both telling them the process then they are more likely to get it done sooner. The squeaky wheel gets greased first after all and I aim to be the squeakiest at this point.

No sooner than I had hung up with Monica, I contacted the ortho’s office. Rather than just lay into them about doing it wrong or just assuming that faxing it to Evicore was the only thing they did, I asked if they could confirm what number the appeal documentation was faxed to on 12/12. They confirmed it was the Evicore fax number and not the fax number Monica had told me was in the appeal instructions that they had been sent. I advised the young woman I was speaking with about the mistake. I provided her with the correct fax number and told her what Monica had said needed to be included with that fax for the appeal to be valid. I also reminded her that the denial fax that had been sent to them by Evicore on 11/28 would have that information so they could verify everything was together before faxing to the correct number.

They said they would take care of it and get everything sent over to the right people ASAP. At this point, I’m not naive enough to think that it will all go smoothly. Nothing about this process has gone smoothly since I walked out of the ortho’s office on that first visit. I will give the office a day to get the appeal opened properly and then I will start pushing for a decision. I need these MRIs done sooner rather than later so maybe I won’t have to spend another 4 months in agony waiting for everyone else to get their shit together.