Fingers crossed and hoping for the best. Good luck!!!

Third and final appeal:DENIED
 

Oh how I hate to even have to say it, but my third and final external appeal was denied this week. :censor:

I saw my surgeon on Wednesday who was so mad at Aetna on my behalf that he called his CEO over from another building and we had a meeting about what direction they are taking next with my case. Apparently he had a patient with the same surgery get approved by Aetna last week.

I asked that they submit in the mean time a request for authorization where Aetna pays for 1 level and I will pay for the other. Done this way it will only cost me about 16k out of pocket. They can deny this option as well, leaving me right back in the appeals process...and I am admittedly getting weary.

I want to remain thankful for the insurance coverage I do have, even in light of this. Some are without, some pay through the nose for insurance that covers nothing, and I know I do have a great plan all in all. Glass half full is where I like my mind to stay. BUT...I sure would like to have surgery now. My hopes are that Aetna will agree with the new plan and I can get my cervical spine stable, as I still have lumbar issues to contend with. After that, if my surgeon and his CEO want to make something of my case and go some rounds with Aetna, have at. It is, and has been the principle of the matter with Aetna, but at some point I need to get fixed!:confused:

Kelly, I know you were probably expecting this denial. On what grounds did they deny this time? Has it been the same reason each time? Or did they provide a different reason each time? Do you know if your doctor used this court case in his appeal? Does your state provide for third party arbitration?

I am stunned that your appeal was denied. What is the next step? Keep fighting because as my experience has shown they want you to give up. DON'T -- keep fighting!

The grounds for denial have been experimental/investigational and not medically necessary. The original request was submitted in January which was denied. This was followed by two appeals that were sent to Aetna, denied for the same reason. The last appeal was a third party reviewer who upheld Aetna's decision. I did include the Cigna court case, as well as every possible smitten of a hint of evidence. There are no more appeals as the external appeal serves as the final decision.

Next steps...I could hire an attorney. The CEO of my Dr.s clinic gave me the contact info for one. The problem with this is you can only sue an insurance company for the cost of the denied procedure (force them to pay.) you can not get reimbursed for attorney fees or any restitution above that. So, what do insurance companies have to loose?? It ends up costing the patient a lot in court costs to get them to pay, when if money were not an issue patients could just pay for the surgery. There is a documented win for the good of all patients if the ruling is against insurance, but as much as I want to push...it's a gamble, and a costly one. The Cigna case you are referring to Jeff was done pro-bono.

I have asked my Dr. to put in the pre-auth request for Aetna to pay for 1 level, and I will pay for 1. This is an option because 1level is acceptable to them and they routinely cover it. This I can afford at 16k, but Aetna could deny this as well, since their clinical policy bulletin states "ADR is considered experimental for patients who have DDD at more than one level" . So the request has been made and now we wait and see. This is plan B. I don't really have a plan C. Not yet anyway.

My Dr and his clinic may decide to do something on my behalf. He called in his CEO at my last appointment. I had the feeling they were in "gather information" mode. My Dr. Was very upset for me, saying things like "they just paid for this same surgery for someone else last week, they can't do this, it's illegal, we are going to hammer them on this, etc" (he also has a degree in law) I have no idea if they will take it up or not. My Dr. Went out of own and won't be back in until next week and I'll talk to him again at that point.

So that's my story, Learning patience has been my lesson. Counting my blessings and appreciating the small things ;)

Lost battle with Aetna
 

After consulting an attorney who reviewed my entire library of case documents, he declined to represent my case against Aetna, saying that since my case concluded with an external review that significantly lowers the chances of prevailing, and since his office takes the case on contingency he didn't want to take the risk.

I could pay up front for his services, and may or may not win. I don't want to take the risk either.

So after almost a year of fighting with Aetna, I will be joining the "pay out of pocket" club.

Surgery is scheduled for January 7, 2015 in Puyallup, WA with Dr. Richard Wohns for a two level cervical with the Mobi-C. And I am so ready to get on with this!

I submitted a request for Aetna to cover 1 level (and I would pay for the other) which of course was denied. Just for fun, I am going to appeal. Kind of like flinging my last arrow into the air and hoping it hits something, haha. Either way, surgery is on my horizon!!!! :D

Kelly,

When we consulted with TBI- Texas Back Institute, they indicated that they were going to approach it in the same way (two-level, but insurance pays for one-level) . I got the impression that TBI works directly with LDR (the disc manufacturer) who has a outside insurance "fixer" that handles the process for them.

May want to ask your doctor. I bet his LDR Sales Rep. can provide insight.

Good Luck!

TJ

Thanks TJ,

LDR actually handled most of my appeals to this point. MCRA is the company contracted with them who submitted a lot of documentation on my behalf. My agent at MCRA is not optimistic since they have given me so much trouble this far about the 1 level getting approval. Yet, Aetna has paid for this very surgery for other patients at my surgical center. Seems unethically and unconstitutionally random. I will try one more appeal anyway, it could save me 20k, but I'm not counting on it.

Don't give up -- they are hoping you will. I am praying for you! You are a fighter!