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-   -   Aetna denied 2 level ADR (https://www.adrsupport.org/forums/showthread.php?t=11321)

Merlinus 09-26-2011 01:55 PM

Aetna denied 2 level ADR
 
Received word at the 11th hour from Aetna via my doctor that they will approve a single level ADR only. Surgery was to be tomorrow 9/27/11, and they called the doctor friday 9/23/11. I've tried to discuss with the doctors staff and with Aetna - they make it their business to stonewall you. Now the doctors office has to reschedule surgery and resubmit for 2 level fusion.
My question to the doctors office was why can't I pay for everything over and above what Aetna won't cover? I can go after Aetna on my own after it's all done, right? The doctor said they don't have a problem with it but the hospital will bill Aetna for everything, period and the Aetna can deny the entire operation!? :puke: I'm scheduled to see the doctor 9/29 to discuss.

My company healthcare administrator will hear about this debacle. I work in the insurance industry, if we gave someone the kind of treatment that I've received I'd be hearing from our president's office having to explain why we PO'd our policyholder! We don't like those emails and do al we can to avoid them.

MeggieLynn 09-26-2011 09:15 PM

Can you see if your doctor will submit it for an ADR at C5-6 and a fusion at the lower level? I thought Aetna was supposed to be ADR friendly - they might go for that. The problem is with having multi-level DDD. They might even consider a hybrid to be experimental. Most health plans in this country will not cover multi-level ADR and they are very specific about it in the plan language. They generally do not deviate from what is written in the SDP - Summary Plan Description. Good luck.

laid up doc 09-26-2011 10:42 PM

"Aetna considers the use of hybrid fusion with artificial disc replacement experimental and investigational for the management of back pain, spinal disorders, and all other indications."

Intervertebral Disc Prostheses

Merlinus 10-07-2011 04:17 PM

Aetna to cover only single level ADR, (I need 2 level)
 
I finally received word from my doctor that Aetna has agreed to cover the first level ADR, even if I am having the second level ADR done at my own expense. I will work out appeals with/against Aetna after having the procedure done. It took some time to convince the doctor's office to do this as they were sure that Aetna would deny everything. They were finally convinced after several calls back and forth to them , myself and Aetna. My surgery is scheduled for October 18th. The doctor expects they will charge me under $5000 for the second level. Well worth it to me, even if I lose all appeals.

colorado babe 11-07-2014 09:39 AM

There is a court ruling on here in favor of the client to get a two level ADR. You should use this in your appeal. I used it for my Tricare appeal and I won but the appeal was through an outside agency (third appeal) . Plus, I used papers on evidence based practices that show it is not investigational. Good luck. Lots of wonderful info and people on these boards that can help you with your appeal when the time comes.

https://www.adrsupport.org/forums/f4...pay-adr-12341/


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