ADRSupport Community - Aetna updating their CPB on ADR 7/10/14

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- - Aetna updating their CPB on ADR 7/10/14 (https://www.adrsupport.org/forums/showthread.php?t=12834)

Hi Kelly,
I just posted in another thread some of the appeal variables that may come into play when looking at outcomes. These include insurance carrier, type of procedure, number of disc levels addressed, support by local docs, and many more. However, I also agree with you that there is some randomness as there are different reps within the insurance carrier reviewing the appeals, different moods they are in, etc.

Bottom line in my opinion is that it is worth it to try to obtain approval or be reimbursed for the surgery. It is also important to manage one's expectations so that you are not terribly disappointed if you are ultimately denied.

Incidentally, Cigna does not accept 2-level cervical ADR as there guidelines have many exceptions. I suspect that it can be random as well.

Quote:

Originally Posted by Kelly4ADR (Post 107945)

I don't understand why they claim ADR is more money when in all actuality ADR is cheaper. Less time in the hospital 23 hours vs 4 days or so. Also, it is no longer experimental -- just show your insurer during your denial that it has been used on patients in the U.S. since 2004-2005 and it is much safer, cheaper and that in than in the future those fusion patients will be returning back most likely for another fusion. There are articles out there in the internet - use them for your appeal.

Colorado babe, it does not make sense does it...that's my point. I personally, over 8 months and 4 debates, have lost my appeal fight. There are no other options for me, unless I pay an attorney which would cost me thousands. I don't know how they can approve the surgery for some, and not others, but they do. I don't want to count your advice as useless, but I do feel you have been blessed with one of the few "lottery tickets" to be granted surgery (paid for) while some of us who are just as deserving are not afforded the same gift, and you assume it came down to your appeal...It's easy for you to say "add this or that in your appeal" as if that has anything to do with the outcome. Reason and logic has no place in this game but chance and circumstance prevail. If you were to read my 82 page final appeal, you would see I left no detail unaddressed and no room for question the logical and ethical reasons for why my surgery shouldn't be allowed. Fair? NO. Reality? YES.

I did have my congressman involved and maybe that was the reason, I don't know. It sure doesn't make sense to me but if anyone wants to use my reversal for their case, pm me and I would be happy to supply it for you. I am with Tricare but I used the Cigna case and it was very helpful.

Aetna has updated their CPB

It appears that Aetna has "updated" their clinical policy bulletin 11/12/14. It also appears that nothing has changed.

Intervertebral Disc Prostheses

Hello Kelly,
I will switch to Aetna, only because it is HDHP and I can get a HSA, but insurance in the USA, since the Communist (My Opinion) (Death Panel) ACA was put in place, won't matter in a year or two (if not REPEALED 100%) anyway.
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All we will have is a Bureau of Motor Vehicle, stand in line type care anyway.
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To compare the ACA to the VA, is Non-Sensical, if this is implemented, it will be NOTHING like the VA.
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BCBS(Blue Communist Blue Socialist) care is about as bad as paying a toll and not using it, I pay A LOT of money, and receive about 40%.
They are denying the Surgeons fees for BOTH of my surgeries.
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This is just ridiculous, if they could only live like that for a few weeks, they would change their tune.