Cigna overturned on appeal
 

I wanted to let the community know about our recent success. My wife had a single level ADR performed on C5/6 in Portland, OR in December, 2010 with a diagnosis of degenerative disc disease and radiculopathy.

All of my internal appeals to Cigna were denied, which is not surprising. I filed an external appeal with IMEDECS, which is one of the independent reviewer organizations (IRO) that was made available to us, and they overturned Cigna's decision not to cover. Cigna is now in the process of reimbursing us for our out-of-pocket expenses.

I have attached my appeal for anyone who is interested. I purchased Laurie's books (The Insurance Warrior), which made all the difference. I also sent our information to her, and she maintains a list of people who have succesfully appealed their insurance companies for ADR surgery.

It was tremendously satisfying to find, and spell out in the appeal, how Cigna broke Oregon state law, and violated the terms of a 2003 federal lawsuit settlement, by not using expert reviewers to deny claims.

In addition, Cigna does cover lumbar ADR, but not cervical. A careful reading of the two policies enabled me to point out the discrepancies between the two. For example, they claim cervical ADR is experimental because the 5 year, post FDA approval results have not been published, but they have covered lumbar ADR within a year of FDA approval, and the 5 year results for it are also not available).

Best of luck to you. I hope you are able to use our information in your fight, and a big thanks to Harrison for maintaining this site, which provides us the information we need to have a fair fight!

this gives me hope!
 

I am currently in a fight with my insurance (United Health Care) and they have denied my claim and then my appeal as well. I'm currently in my second appeal where it will go to an IRO but it is in the very early stages. So I hope I get to have the same result as you!

Im working with an advocate, and they are putting together my appeal. But Im hoping to hear back soon to see if its overturned and that I can have my surgery by the end of the year... Yeah Im not holding my breath!

Best wishes from California for you and your wife.

Thank you for the Cigna appeal. I read the appeal once and it will be read again. The Federal references are interesting.

Awesome! Congratulations on the big victory. I love to hear about situations-- albeit stressful, complicated and frustrating-- were the outcome favors those in true dire need of help and were medicine/science & law JUSTIFIES proper medical use of these so-called "INVESTIGATIONAL MEDICAL DEVICES". I must say that I was fortunate to have an insurance- Aetna- that does cover ADR with the Prodisc L but I was going to be in for a long and hard fight if I did decide to go with a TLIF (fusion) because this procedure IS NOT a covered procedure even with proper coding and CPT codes. For the longest time and no matter what research I did or how hard I tried, there was apparently no doctor (neuro/ortho) that performed ADR surgery because they merely were not up to date on the latest technology. Luckily I found a very good expert and knowledgeable surgeon who I now-- if I could do back flips I would-- because thus far my results and progress have been favorable. I believe one other person on the forum- laidupdoc- is having this problem now with Aetna as this individual is possibly allergic to the metal(s) that are a component of the Prodisc L and Aetna's stance is that they don't pay for a fusion for discogenic pain. What a bunch of bull crap!!!!!:chainsaw: So again congratulations on your victory and I will also hold on to the appeal in my files because there are other individuals in my area that I know of who are currently in appeal status', although with different insurance!

janaya -

i am indeed allergic to nickel, and looked into the out of pocket cost for a TLIF. it was in the 6 figures. prodisc does contain a small amnt of nickel, and i've been advised not to get it. gotta get all of this in writing to construct my appeal. looks like i'll be paying cash for an M6 and hoping i get something back either from aetna or my personal injury suit from the mva...

So is this the uninsured/under insured price-discounted rate that most hospital apply? They typically apply the highest rate to "self-pay" patient but discount anywhere upward of up to 60%. This was the policy of the hospital were I had my surgery and was explained to me prior to signing any financial responsibility documents.

Wow 6 figures for a TLIF!!!!!!! That is approximately 2.5x more than what Aetna paid out for my Prodisc L procedure. The hospital was payed an aggregated (negotiated) lump sum of $37,082 out of a total possible billed amount of $77,147. The independent doctor fees that were paid out were $1,637 to the neurosurgeon, $2,308 to the anesthesiologist, $1,637 for the general surgeon.

The price of a TLIF seems overinflated but am also left wondering if there is justification for this maybe the mere fact that surgical procedure itself is more involved-time consuming and the hospital stay must be a bit longer, but I am only guessing.

?Well with your decision to do the M6 L you are definitely getting better technology and your moneys worth, in my opinion and for what my .02 cents are worth!? (Not clear if this is the route you are taking though)

Thanks for sharing this information -- which will help many people!

Thank you for this document. I have a very similar history and also had to pay out of pocket for my cervical disc replacement.

Wonderful!
 

Thanks SO MUCH for sharing this! Congratulations! I too, bought the Insurance Warriors book and getting ready for the possible fight. This will help so many of us!
Congrats!