Need Aetna help

[JasonR]

All, Aetna provides umbrella coverage to my company which is self insured. They have denied coverage for my ADR claiming that nobody covers that procedure currently. I've heard of Aetna covering the procedure and was wondering if anyone can provide prrof that a Cervical ADR was covered by Aetna. My HR VP is trying to get it covered but because we're self insured we have to get Aetna to agree to provide umbrella coverage. My company would pay to a certain point but needs coverage in case things go wrong.

Any help is greatly appreciated.

Thanks,

Jason

[trkdoc714]

Jason,

Aetna's cover page of THEIR Clinical Policy Bulliten 0591 clearly states that cervical ADR is covered:

II. Aetna considers FDA-approved prosthetic intervertebral discs(e.g. the Prestige Cervical Disc, ProDisc-C Total Disc Replacement) medically necessary for the treatment of skeletally mature persons with cervical degenerative disc disease at one level from C3 to C7, andwho have failed at least six weeks of conservative management.

You can access this on their website Aetna.com to look at their Clinical Policy Bulletins.

Good luck Jason,

Bob

[JasonR]

Hey Bob, I found that too :). Sent it along to my HR VP and told her that IMO that's a smoking gun in our favor. They psuhed back originally saying it was still investigational. Wonder what they'll say this time.

[kimmers]

JasonR,

They (Aetna) have covered this numerous times. Maybe the Aetna person is giving you the run around??
I have heard they might not approve on first attempt but look at what the policy says.

Keep at them.

Kimmers

[trkdoc714]

I'm not sure. I was told by my employee services department today that if I went overseas, no procedure would be covered unless it was a sudden illness or accident. We're self insured, Aetna only administers our insurance.

I'm trying to work my way up to someone that can make the decision but it looks like it will take time.

In the meantime, I'm preparing to remortgage the house, clean out the savings and head east. I'm not putting life on hold any longer.

Keep me up to date. I'm hoping you get much different results!

Bob

[JasonR]

I'm not sure. I was told by my employee services department today that if I went overseas, no procedure would be covered unless it was a sudden illness or accident. We're self insured, Aetna only administers our insurance.

I'm trying to work my way up to someone that can make the decision but it looks like it will take time.

In the meantime, I'm preparing to remortgage the house, clean out the savings and head east. I'm not putting life on hold any longer.

Keep me up to date. I'm hoping you get much different results!

Bob

I'm in the same situation Bob. We're self insured with Aetna providing ballon coverage. Not sure if that makes a difference in their policy. It is frustrating. Essentially, my employer is on hook for 100% of the surgery barring a problem. Aetna would only get involved if there were a significant complication which is unlikely. Yet they still say no.

We'll see how it goes. My HR VP forwarded their own policy to them today and we're waiting on their response.

[Deborah]

This Aetna thing really suprises me... I guess maybe the balloon coverage aspect of it could make a difference. I'd suggest you also talk to Prodisc (if that's the type disk you anticipate using) as they have stated Aetna has covered a number of TDR's. The doctors we consulted with at TBI also said it's 'routine' with Aetna. I think you can win this one with a bit of perseverence (not easy, I know). We had to stand firm a long time for coverage for my hub's lumbar hybrid (different insurance). I think cervical should actually be an easier fight to win with such good trial results.

Good luck!

[JasonR]

This Aetna thing really suprises me... I guess maybe the balloon coverage aspect of it could make a difference. I'd suggest you also talk to Prodisc (if that's the type disk you anticipate using) as they have stated Aetna has covered a number of TDR's. The doctors we consulted with at TBI also said it's 'routine' with Aetna. I think you can win this one with a bit of perseverence (not easy, I know). We had to stand firm a long time for coverage for my hub's lumbar hybrid (different insurance). I think cervical should actually be an easier fight to win with such good trial results.

Good luck!

I was surpised at first too. It's been two weeks now since I sent them their own policy bulletin stating they cover it and we haven't heard anything back yet. I keep hoping that it was nothing more than a lazy employee just going along with the previous denials.

[trkdoc714]

Jason,

I called the employee services group back and got to a supervisor. It took her 3 days but Aetna conceded to "out of network" coverage, 50%. That's better than two weeks ago at least.

Don't give up on Aetna. You may have to ask to speak to supervisors a few times. If your company is self insured, HR may be able to put pressure on the situation.

Don't give up Jason,

Bob

[JasonR]

Jason,

I called the employee services group back and got to a supervisor. It took her 3 days but Aetna conceded to "out of network" coverage, 50%. That's better than two weeks ago at least.

Don't give up on Aetna. You may have to ask to speak to supervisors a few times. If your company is self insured, HR may be able to put pressure on the situation.

Don't give up Jason,

Bob

Hmm, would they cover Germany that way? I alomost wonder if it would be worth it to get the newer technology. Of course, newer doesn't always mean better but I'm starting to look at an overseas trip as a backup if the Bryan disc doesn't get approved. And I haven't given up hope yet. It's been a couple weeks since my HR VP sent them their own policy bulletin and we haven't heard back yet. I'm assuming that's a good thing because if nothing else they're having to scurry around trying to think of another excuse other than "the procedure is uninsurable."

My wife and i have decided that if ADR is the recommendation than we will do everything reasonable to make sure that's what I get. The thought of complications not being covered is scary though.

[sheljel]

Hi Jason,

Aetna covered my ADR (Prodisc-C) on 03/06/09. Do you have a neurosurgeon working with you to get Aetna on board? My doc had my ADR approved from Aetna in one day.

Best of luck. Like others have said, don't give up.

- Michele

[JasonR]

Good news! I was told yesterday afternoon that Aetna had reversed ActiveHealth's decisions to deny the surgery. Basically ActiveHealth was NOT following Aetna's guidelines even though they are owned by Aetna. It's taken almost 4 months but at least it went my way.

Now if the FDA would just approve the Bryan disc. Little birdie told me that approval is probably coming within the next month.....

[treefrog]

That is good news Jason. I'm very happy for you. Now I will be hoping that the Bryan disc gets approved, and that Aetna will also approve using that disc for you.

[steve55]

Good news! I was told yesterday afternoon that Aetna had reversed ActiveHealth's decisions to deny the surgery. Basically ActiveHealth was NOT following Aetna's guidelines even though they are owned by Aetna. It's taken almost 4 months but at least it went my way.

Now if the FDA would just approve the Bryan disc. Little birdie told me that approval is probably coming within the next month.....

Aetna makes this way on purpose. They know this. But they want active health to initially deny and hope the client doesnt catch on. Here is another situation just like yours:

"In short time my HR VP was asking our Aetna rep why it kept getting denied as experimental when it was FDA approved. Aetna denied the procedure again saying that the screening company, ActiveHealth, had correctly researched my issue and explained their decision.

At this point I found an Aetna policy bulletin that explicitly stated that ADR's were supported. My HR VP again demanded from Aetna how their policy could be so clear yet I be denied coverage. She was told that my case was being sent to a review board to ensure that ActiveHealth was making decisions in accordance with Aetna's policies.

3 long weeks later on the same day I let my VP know that I had sent my info to Stenum for review she emailed me back and said she was on the phone with Aetna and the denial had finally been reversed."

They are DOGS , no they are SLIME! They know the game, they j ust hope most people give up after the initial denial. Its easy enough for aetna to tell active health that ADR is covered, hell, active health knows this too. You and I are just 2 of what is probably 200 cases a year where this routine, or shall we say , "dog and pony" show goes on. SO shameful they are!!