Sonya was no stranger to hard labor and the occasional back pain, but the pain that brought her to our clinic was like no other backache she had experienced before. It was sharp, focused in the middle of her upper back and it had appeared instantly as she leaned over to pick up her grandson, Ivan.
Her x-rays showed a compression fracture and her bloodwork was normal. Her bone density had been borderline about four years ago, so it seemed this probably was “just” an osteoporotic fracture and not a sign of anything more ominous. The MRI did not suggest cancer. Reassured, she took pain pills and limited her activities for the next several weeks, but the pain was unrelenting.
Sonya seemed to be a good candidate for a vertebroplasty, a procedure where a type of cement is injected into the collapsed vertebra. I referred her to Joe Dugan, an affable orthopedist with a special interest in vertebroplasties. Joe agreed and went on to schedule the procedure.
A week went by and Sonya didn’t hear anything. Then yesterday I got a message that I needed to speak with a physician reviewer about her procedure.
After several minutes of phone tree tribulations, it was clear that I would not be able to get anywhere with Consolidated Insurance, since I did not have access to Sonya’s policy number. All I had in my message was the case number, but the automated telephone attendant wouldn’t accept that number.
Finally I gave up and asked Autumn to get me a better number for the physician reviewer, which she did, effortlessly.
The ensuing conversation made me nauseous. The jargon-swinging doctor at the other end of the line (actually, he faded in and out, and might have been on a cell phone) asked me if Sonya had osteoporosis.
“Well, she suffered a compression fracture picking up her grandson”, I answered.
“Has she had a bone density?” he asked.
“A couple of years ago”, I answered, “showing osteopenia”.
“Unless she has osteoporosis on a bone density test or cancer, her policy doesn’t cover vertebroplasty”, he said.
“But why else would she get the fracture, not skydiving or anything, but just picking up her grandson?” I asked, my head spinning. “Is a picture of her hip and lumbar spine really going to prove to you she doesn’t have osteoporosis in her upper back when she has had a spontaneous fracture?”
“I’m sorry, without a bone density to prove it, we cannot cover the procedure”, he said again.
The man was not acting or thinking like a doctor. There was no empathy, wisdom or compassion. I felt like I had watched a court room television drama, where the bad guy got off on a technicality.
Sonya’s insurance company is a large national for-profit conglomerate.
She will have a new bone density test, but the bigger question remains: What is osteoporosis? Bones that break easily or bones that appear thin in pictures? Are we treating patients or pictures of patients?
A Country Doctor Writes: 
I have admired many of your articles, but this one prompts me to write. In the field of Chinese Medicine, I was taught this principle in my first week of medical school. People are not their symptoms, not their images (as you so appropriately emphasize), not their health policy “coverage.” And yet, so often in Western medicine, this is exactly how the case proceeds. These abstractions make any doctor (East or West) worth their salt cringe… and turns the art of diagnosis into some “Medicine for Dummies” version of the process.
So often a relatively simple procedure would *prevent* something ghastly and ‘way more costly down the line, but isn’t covered yet because things haven’t deteriorated into the Worst Case Scenario yet. Grrr. Wasteful.
If it makes you feel any better, kyphoplasty and vertebroplasty aren’t really well supported according to some recent publications, despite making such logical sense.
http://www.ncbi.nlm.nih.gov/pubmed/22425141
http://www.ncbi.nlm.nih.gov/pubmed/19657122
http://www.ncbi.nlm.nih.gov/pubmed/22883654
http://www.ncbi.nlm.nih.gov/pubmed/21750078
Touché. Sometimes we hope a procedure will help. I have just sent an appeal to the insurance company.
Viewed from far away Australia it often seems that private medical insurance companies in the US are more intent on denying help to their customers rather than giving them timely assistance. More to do with ensuring profits than fulfilling promises. Fortunately, patients here with osteoporotic crush fractures can access subsidised bisphosphonates if they have either a low BMD on DEXA scan or if their have a history of a typical osteoporotic fracture.
Vertebroplasty was removed from the Medicare medical benefits schedule in 2011 after the Mayo Clinic and Monash University studies showed no difference between it and placebo. Though other studies suggest that it is beneficial. If I had a severely painful vertebral crush fracture that was not improving with conservative therapy I’d certainly be tempted to give vertebroplasty a go. It seems to have a low compliction rate and certainly gives good relief to some patients. If it works a win is a win and better than suffering both pain and the anguish of making a contraversial clinical decision.
Insurance companies don’t care about patients. They care about statistics and pictures and of course money.