Cervical two level: Aetna
 

I am in need of a two level cervical ADR. I have Aetna PPO out of Lexington, KY. I live near Seattle, WA.

I haven't received a denial from Aetna yet, but I am anticipating one.


Does anyone have experience with A TWO LEVEL CERVICAL ADR APPROVAL WITH AETNA?


Any information about the appeal process would be very much appreciated.


Thank you!!!

Phase one: Aetna Denied
 

I am tracking my insurance progress on this thread to hopefully give some insight to others...

I saw Dr. Wohns at Neospine Clinic in Puyallup, WA on Feb 14, 2014

He confirmed that I need a two level disc surgery at C5-6 and C6-7. He did not recommend fusion but recommended ADR. Explained how mobi-c is now FDA approved for two level cervical. Then I said "lets talk about insurance..."

His response was that his clinic was having a really good track record of getting ADR's paid by insurance. I asked him about a two level... He said that is a little harder but they are seeing it be approved. Worse case, Aetna will pay for one level, I will pay out of pocket for the second, but it would be under 15K.

Feb 14, the day of my apt was a Friday. The following Monday their office was closed due to Presidents day. On Tuesday the 18th, his office put in the request for the pre-auth for the two level cervical ADR.

The next day, Feb 19, Aetna requested a questionnaire be filled out by the surgeon. They filled it out and sent it back on the 20th, Thursday.

Today is the 24th, Monday. I received a call from my surgeon's office stating Aetna denied. On the voice mail she explained that they were prepared to do a peer to peer Appeal involving their surgeons. If that gets denied, she will send another appeal. I called her back to discuss, but was unable to connect with her today.

I ordered Laurie Todd's book on insurance appeals.

To be continued....

Good luck with those appeals. Be sure to reference the court case(forget which one it is) where someone had sued COBRA i believe it was for not approving a 2-level ADR procedure....they WON.

Thanks Bwink. It was Cigna ;) I will include it for sure. But...ugh. I'm exhausted. Just trying to figure out who to cc at Aetna is mind blowing. "The director of who?" The board of what?" Jeesh.

If anybody out there has precedent for two level cervical ADR with Aetna, please please let me know. I don't been care if they were reimbursed after having care in Germany either. ANYTHING WILL HELP. It is practically impossible to gather this info due to HIPAA, and even if the patients agree to let me use their case I can't find out who they are because of HIPAA, and on and on.

Cervical Two Level ADR approved for Category I CPT Code
 

My Surgeon's staff sent my first appeal off yesterday. Included along with my appeal they sent a letter from the North American Spine Society Dated March 3, 2014. It states that NASS was sucessful in obtaining a new category 1 CPT code for two level Cervical total disc arthroplasty. They added this code and also revised the existing category III CPT code to describe three or more level arthroplasty. The change will take place on January 1, 2015. I have attached a copy if anyone needs to use this as part of their appeal. :wiggle:

Update: There are no new updates
 

I called my spine clinic about 10 days after she said she sent the appeal to Aetna. She called me back the next day, saying that she called Aetna to follow up and they said "we never received it". She faxed it to them again that day and said she will be checking with them every few days. So I will be calling her every few days to check that she checked with them. Because I have nothing better to do and this is really fun for me. Not. :beer:

ADR companies will help you with appeal
 

Still waiting to hear from Aetna regarding the first appeal that my surgeon sent. Although they did send me a postcard stating that they received it and will be reviewing it. I did, however, contact my spine clinic and asked them what's next if Aetna denies the appeal. She gave me the number to a business in CA that deals with appeal help, so I called there and left a message. The next day I got a call from my spine clinic. Apparently the rep from the business in CA that she referred me to doesn't help patients, only businesses. The rep called her and told her to have me stop calling. :wtf: then she said they were contacting LDR to see who could help me. An LDR rep gave them a number for me to call... The LDR reimbursement and appeals dept. (LDR makes mobi-c, the cervical device I am waiting for). Of course they have a dept such as this, they want to sell their product. :kiss: so, I called them! And... She wouldn't talk with me because they have to work through the surgeons office. So... I called the spine clinic back, and asked her to send the release to me so I could sign so she could talk with them. She sent the release and I called LDR back and she talked to me this time, explaining if Aetna denies the request that has been submitted, then LDR can send an appeal on behalf of my surgeon. If that is denied then they will send one on my behalf. They already have an appeal packet ready to go. I would just plug in my personal info and sign. This is a relief to know since I have already started an appeal and it is very taxing. It is a lot of info to try to gather and organize. I know it seems as if I'm talking a lot about nothing, but maybe these two things can be helpful to someone:

1) If you need to appeal your insurance decision, call the company of the prosthetic you are seeking. They can probably help you.

2) if at first you don't succeed, try...try (or call...call ) again. We are our best advocates.:shedance:

Kelly,

Good luck. We're all holding our breath.

BTW the same thing happened to me. I sent in the original claim and waited weeks without hearing anything; only to have BCBS-TX claim to have not received it.

Good luck!

Jeff

Adr
 

Kelly,
I am with you, I have been going after this for months, I just submitted my claim to BCBS, International, and sent them the information from the german hospital (ONZ), and my most recent MRI.
I have had to call them a couple of times.

The first, I had submitted the wrong type of claim, and so she was nice enough to process this on the phone, and gave me a new claim number.
Then I had to call a few business days later, and they said they needed the above information.
She was surprised I had all this, called the following day, and another agent, and she said they had reviewed or had started to process this information.

From what I know, this can take a business week.

For all the effort they put into making you take tests, and use conservative methods, (I am still getting requests for information, about the last surgery, the discectomy) and all the agents you have to spend time with, they would be better off, just paying for the surgery, the ADR, and be done with it.

There have been failures, but these have been documented, and the later generation discs, namely, the M6, has had very good results.

You are right, No One will look out for your interests, they will do what they can to keep you from this treatment.

One other point, thank you for the information, getting the Spinal Kinetics involved, I have contacted them once, about timing, but not about help appealing.
I have emailed the FDA also, she came back and said the M6 is 'approved' for Export Sale only, how do they figure this?

Jerry,

Hang in there! It's frustrating, I know. I have dealt with insurance companies for 15 years with my massage business. In the last two years or so we have been receiving a crazy high number of denials for very stupid reasons for massage treatment. This is not an expensive treatment in the insurance business, yet they don't even want to pay for that these days, let alone an expensive surgery.

What I have learned is they bank on those people who won't try to fight it, those who don't know they can, or those who are in too much pain to wait it out. Fortunately, I am not in any of those situations.

For me, it would be different if the denial was for a valid reason. If they deny due to "experimental/investigational" and it actually was, I could trust that they don't want to pay for treatment that might harm people. But, when they use this blanket statement as a first level automatic rebound, full well knowing there is plenty of proof otherwise, it makes me mad. :mad: not to mention the fact that my spine clinic has had this exact same surgery paid by my insurance four times before? I'm willing to jump through hoops just for the principle of it all.

I would recommend picking a day of the week to deal with insurance issues, whether it be appeal prep, phone calls, research, etc. make sure you check with insurance once a week if you are waiting on something, otherwise you could wait a month to call them and hear the infamous "we never got it". Then, the rest of the week, live your life. Take care of yourself and remember to do small things to help your pain, etc. it is so easy to fall into the trap of focusing so much time and energy on being mad at insurance and waiting for surgery to cure you, that we forget to live our life. I had to consciously decide not to let this consume me.

You said you saw a VA MD? What branch of the service/era were you in? Have you tried any other VA resources to help you with the process? My dad and husband are both Marines, veterans of Vietnam (dad) and Gulf War (husband). The VA has come a long way providing resources to veterans, so much so that my dad is seeking services that he swore he never would because they have actually been helpful.

First Appeal Denied
 

I talked to my spine clinic last Thursday prompting her to call Aetna and check on the appeal status: Denied for the same reason experimental/investigational.

On to round two...

Kelly,

Here's the synopsis of my four rounds with BCBS-TX.

- Submitted claim
- BCBS - denied as not medically necessary
- Submitted appeal showing medical necessity
- BCBS - denied as investigational
- Submitted appeal showing almost 1000 years of clinical data
- BCBS - denied stating that approval was against company policy
- My employer objected to the absurdity of "company policy"
- BCBS - denied stating that the contract allowed them to deny if I went out of US

Thanks for the update and keep on them. Insurance companies seem to be drifting away from the trend of "deny for any reason", as demonstrated in my case by BCBS-TX.

Good luck, Jeff

Thanks Jeff, and sorry you had to paddle up the same creek :insane: I'll be patiently pressing on in hopes that I clear a path for those behind me :) As well as saving myself thousands $$$

Continue
 

BCBS is the only game in town, well except yours, so we really don't have any choice, this is the game they play.

If they would just admit their is a better alternative, and quit paying for all these conservative measures, and eating up our allotments, then people would be more productive and there would be a better return on investment.

The insurance Companies are always, and have been, involved with politicians, this is the biggest, single obstacle to good health care and insurance.

There are only two options, an ADR or run the risk of more damage, and get by with pain drugs.

:insane:

Surgeon appeals second time
 

My spine clinic emailed me today to say that my surgeon worked with LDR (mobi-c manufacturer) , signed and sent the second appeal off via fax to Aetna today. She sent me a copy. If anyone would like to see it PM me with your email and I'll forward. If it gets approved ill post it in the approved appeals thread. I am anticipating that it won't, however. :sulkoff:

Second appeal sent by surgeon DENIED
 

Errrr. :raspberry: Not that I expected any different. My surgeon's second appeal has been denied. I am admittedly, for the first time in this process, very bummed about this. But, that is what insurance companies count on, that you will give up.

I feel fortunate for so many reasons. Mostly that I am not in too much pain and that I can wait for surgery and continue fighting for insurance coverage.

I've already been working on my last and largest appeal, the one that will be sent by me, in anticipation that I will have to fight this till every last option is exhausted. Thanks to this forum, Laurie Todd's book, a few kind people who shared their appeals and my ever persistent researching self, I should have a good case prepared by the end of the week. LDR has also kindly stepped in, and will send an appeal on my behalf. Although this is tempting, I've decided to include their information in my appeal, but not use theirs as my sole defense. When I read the one prepared for my surgeon by them, it was very well thought out and put together, with all the medical jargon and statistics etc that I never could've put together on my own, but it is very mobi-c specific, which leaves out all other important case studies, clinical trials, law suits etc that collectively could have a greater impact for my rebuttal. Although I am seeking a two level with mobi-c I think it's better to include everything.

For those of you who wrote your own appeals, did you bind it? Did you send it to higher up's than the appeal department at your insurance co? Did you fax it or send it certified mail? Any other info would be helpful. :)

Best of luck Kelly.

Ranting and venting
 

I am so frustrated. Nothing has changed other than I received a copy of the denial in writing today. They state the denial is based on the FDA has not approved a cervical two level. AND THE FDA HAS APPROVED A TWO LEVEL. Do they think they can just lie? Do they think I don't know that the FDA has approved? Did they not read the appeal paperwork that includes the FDA approval???? I feel like this is nothing more than a delay tactic and I AM IN PAIN AND IMPATIENT. I am trying not to take it personal,but just for today, I'm letting it be personal and I am mad! On the other hand, now I can have an external review. I hope that whomever looks over my last chance appeal realizes just because the insurance co says something, doesn't mean its true. .;$!!@%#£>?!!:raspberry: thanks for listening. Had to get that out. I feel better.

External Appeal
 

My third and final round of appeal is being sent in the morning. I'm very thankful that I had so much help from My Dr. And his staff, as well as Gail at MCRA who finalized my appeal paperwork, including letters and chart notes from my Drs, the documents prepared by me personally and her 81 page packet of support documents. Any prayer warriors out there, feel free to offer some words up for me.

I'll post the results of the determination when I receive it, of course!

Drum roll please......

Hope for the best,
 

The insurance industry is on it's last leg, if the ACA is not repealed in 2015, then it is curtains, they will not tell you the real reason, this is so they can have two levels of insurance, really it will be Public insurance, and then those that can afford the care out of pocket.

IOW, they have destroyed the insurance industry.

I decided to have this done, I will pay, hope for reimbursement.

Hope your appeal goes well.

You might have a chance, the Mobi-C was approved in the USA, keep at it, the insurance needs to learn, and I hope the Congress gets a real wake up call this year, 2014. The FDA is one of those regulatory agencies that should be abolished.

Other info, at a post earlier, back in April, I said 'their' and should have said 'there' is a better alternative, slip on my part.

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!