Guaranteed Healthcare

I am insured through my husband's work and we have Blue Cross PPO small business plan. I'm a critical care registered nurse who has worked in this area for nearly nine years. I work for a hospital and for a registry.

On the morning of May 24, I woke up with back pain. I went to work that night and could barely finish because of muscle spasms. I have not worked since that night. I sought conservative treatment when my symptoms did not subside. My primary MD prescribed anti-inflammatories, short bed rest, muscle relaxant and physical therapy. Blue Cross plan limits are 24 visits per year regardless of what you are treated for. Unfortunately, I sought physical therapy treatment for a leg injury suffered when I fell putting my two-year-old son in our mini-van and for a torn plantar fascia on my right foot. So I used up my allotted PT. My physical therapy office requested further care for my newly-diagnosed muscular-skeletal lower back injury.

After a delay, I was granted 12 visits from June 11 to July 11. I didn't improve significantly and was referred to a back specialist, both by PT and my primary md Dr. Matthew Zeller. Dr. Edmund Evangelista, a physical medicine and rehabilitation MD thought I had torn a disc. An MRI done on June 27 confirmed that I had a herniated disc between lumbar vertebra 4 and 5, resulting in moderate left L4-5 neural foraminal enroachment. I was prescribed Flexeril, muscle relaxant, continued anti-inflammatories and a short dose of predisone.

Since not being in PT, my condition has worsened. I now have sciatica, numbness in both feet. My back doctor has told me to not lift anything heavy, sit for more than 20 to 30 minutes, avoid any aggravation to my back and to "lay low" to allow the disc to heal. Both Dr. E and PT have recommended and requested PT to enable me to get back to work (I'm currently on state disability).

Today, I called BC and after being routed to several different voice mails and persons I had to leave the house and take my children to the doctor as I was on hold after 50 minutes. I also called the RN case manager on my case and left a voice message for her to return my call. She returned my call to promply tell me my claim for PT had been denied since I had used up 36 PT visits for my disc herniation. I explained to her that I had only had 12 visits for the disc herniation and the standard of care for disc herniation included PT, I also told her I was a critical care nurse. She explained to me it wasn't her fault that I was denied. I asked why didn't they contact my back specialist (Dr. Zeller hadn't seen me in 4 1/2 weeks!!!!) She said Dr. Zeller was the contact doctor.

I had earlier spoken to the physcial therapy's secretary who had called the case manager earlier in the day and been told the matter was under review and they would have an answer within five business days. I told the case manager it was incredulous what BC had done. She told me the matter was a done deal and my only recourse was to appeal the decision. I requested an appeal, but not before I asked her how she could do this as a case manager, how much experience she had and how she could work for BC. She told me she had been a nurse for 38 years and I told her we had RNs with five years of experience that treated patients better and advocated for them.

So this is my story. I'm scheduled to have an epidural spinal injection today (July 26) and I'm in a whole lot of pain, which today didn't even completely go away with pain medication and Flexeril. I was in pain when I spoke to Beth Davis, a so-called case manager for BC, on the phone and I'm extemely upset because Tuesday I saw my back doctor and he said with a trial of spinal injections and core-strengthening, and treatment with physical therapists I should soon be able to return to my job--critical care nursing--which I dearly love. Blue Cross also messed up in other ways--loosing paper work, taking a long time to return calls to providers, etc.. Thank you, KIM KUTCHER, RN,ASN,CCRN.