ADRSupport Community - Pacific Northwest getting ADR approvals:

Hello,

Ive posted a few times already seeking out information on the appeal process since I am anticipating a two level cervical denial from Aetna.

I spoke with a different surgeon today...Dr. Richard Wohns in Puyallup, WA. His clinic is called Neospine. He is an attorney as well as a neurosurgeon. His credentials are extremely impressive.

After my eval he concluded that I do need c5-6 and c6-7 surgically repaired. No discogram needed, dont waste time with and ESI he said, but he also said he would do it in the mean time if I wanted to see if it would take the edge off the pain. Then the topic of insurance came up....

He said that almost every insurance is covering a cervical one level at his clinic. (We did not discuss lumbar since that is not my problem.) He was also fairly certain I might get the two level approved through Aetna.

He said worse case, Aetna will pick up the one level, and I can pay out of pocket for the second. He further explained that his clinic charges to the insurance company $30k for a 1 level. The insurance doesnt pay that amount, they have a contracted rate which is considerably less. The Dr and his clinic is an in network provider so he accepts a contracted rate. A two level surgery is not double the cost, but more like $45k. So the $15 for the second level is also discounted and far less for me out of pocket. This is assuming that they will not approve the two level in its entirety.

Then I asked him about the appeals process. If they deny the two level, can you submit an appeal?

He said yes, depending on what the denial states and the track record...He states his office has worked really hard at pushing the appeals and has gained much progress. They have a track record of which denials are worth pushing an appeal and which are really not, based on the verbiage in the denial. They will call me and discuss any issues when they receive Aetna's reply, hopefully within the next couple weeks.

Lastly, I told him about this forum and that I had met a patient of his on here. He was presently surprised and seemed happy that I had such a place for support. I also mentioned to him that people are still going to Germany and other countries for disc replacements due to insurance denial in the States. He seemed to think this wasn't happening so much anymore. I guess since his clinic is having such good results, and again he stated that he has worked really hard to change that. He thought maybe the mid states and east werent having as good of results.

I am posting this as informational, as I do not have an approval yet personally, but I will be sure to post the outcome either way and keep everyone informed. I hope someone can find this information helpful.:jacks: