LUTZ, Fla. — A Lutz woman is fighting her health insurance company after Florida Blue approved her spine surgery, then denied the same procedure months later, calling it "experimental or investigational."
Sherri Kelley's medical nightmare began during what should have been a routine evening walk with her dog, Merci.
She tripped on parts from a neighbor's disassembled golf cart and fell hard on her back.
Watch full report from Adam Walser
"I stepped on whatever it was and just went straight down on my butt," Kelley said.
Months of pain followed. Chiropractic treatment and medication didn't help, so Kelley saw a board-certified neurosurgeon who recommended four procedures in one surgery at an estimated cost of $150,000.
Florida Blue initially approved all four procedures on February 25. Kelley was scheduled for surgery in May, but had to postpone after her father died in April, and she needed to handle his estate in Maine.
When her doctor resubmitted the authorization after she returned, Florida Blue denied it.
“A different and inexcusable outcome”
"Florida Blue sent me a thick packet of denials for a lot of different reasons, and they came out and said that the surgery was experimental and investigational," Kelley said.
Dr. Bill Hennessey, a licensed physician who owns a business that helps clients appeal denied claims, questions how the same procedures could be approved then denied.
"Pre-authorizations are typically assigned like a 10-to-15-digit number, and they're typically good for about 30 days. That would mean the pre-authorization ran out, and when it went through the same process again, there's a different and inexcusable outcome," Hennessey said.
Hennessey also questions why Florida Blue now considers the treatment experimental.
"I'm a board-certified physical medicine rehabilitation specialist who saw thousands of spine patients and worked closely with neurosurgeons. Multi-level spine surgery has been going on as long as I've been a doctor and longer," he said.
After Kelley appealed twice and lost, her records were sent to an independent medical review company called Dane Street, which has an office in Palm Beach Gardens.
"Florida Blue selected them. I didn't get to select them," Kelley said.
The review wasn't conducted by a specialist in the same field as Kelley's neurosurgeon.
Instead, Dane Street assigned an internist—a primary care physician trained in Jordan, based in Oklahoma, with no specialties or staff privileges, according to the Florida Board of Health.
Kelley now wears a neck brace multiple times daily and describes it as "very uncomfortable."
Her doctor submitted documents to get surgery approved for her most damaged disc, but that would only solve part of the problem and require multiple surgeries instead of one comprehensive procedure.
Florida Blue approved that procedure days after the I-Team inquired about Kelley’s case.
She says she’s still not satisfied with the outcome, because Florida Blue will not pay for the original procedures her in-network doctor prescribed.
"How's that make you feel?" she was asked.
"Exhausted," Kelley replied.
We contacted Florida Blue, and they declined an on-camera interview.
A spokesperson provided a statement instead.
Statement from Florida Blue – attributed to Florida Blue spokesperson
“We are unable to comment on individual cases due to Health Insurance Portability and Accountability Act (HIPAA) privacy concerns. We understand that navigating health care can sometimes be complex and strive to make it easier for our members to get the care they need. We are committed to providing personalized support to our members, ensuring they understand their benefits and coverage and have access to high-quality health care that supports their overall health and well-being.”
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Adam Walser has spent more than a decade fighting for what’s right in Tampa Bay as part of the I-Team. He’s helped expose flaws in Florida’s eldercare system and held leaders accountable for how they use your tax dollars. Reach out to Adam with any issue you think he needs to investigate.
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