1-level Mobi-C denied by Aetna. What now?
 

So Aetna denied my insurance authorization for a 1-level ADR with the Mobi-C implant. My surgeon's office said that they had already written out a detailed spinal history and explanation for the need for an ADR over a fusion. They said the next step is a peer-to-peer review with the surgeon and Aetna.

I've read through some of the insurance nightmares on here, including those involving Aetna, but I'm perhaps naively hoping that ADR is becoming less difficult to approve. I'm wondering if anyone has some ballpark timeline expectations--like how long after a peer-to-peer review do you typically see a decision made? A day? A week? 1 million years??

If the peer-to-peer review fails, I assume I can still appeal, but I also assume that this becomes exponentially more difficult (and time consuming) with each denial. I'm having more and more weakness and spinal cord symptoms in my hands, and I don't want to get stuck in insurance purgatory for the next six months just watching things get worse. Any advice would be helpful!

Jin,

As you may know, some people have had their 2 level ADRs covered by their insurance:

https://www.adrsupport.org/forums/sh...aetna+approval

Granted, they had out of network coverage; but this is a precedent.

Did you use the search function to identify all the Aetna-related topics?

BTW, cervical fusion is not a bad solution. I know many folks that had these YEARS ago and still doing well.

I'm thinking part of my problem is that I have "Aetna student health," which is like basically crappy Aetna light...I'm assuming they'll do whatever they can do deny anything and everything. I've already struggled just getting diagnostics and more conservative treatments covered.

My surgeon is in-network, and it's only a one-level procedure, so that shouldn't be part of the issue. I went through the search function and I was just hoping things had improved over time as ADR's getting more accepted as not experimental. I couldn't really get a sense of the timeline, which is what I'm really worried about.

As for the fusion, I'm terrified of it. I'm actually wondering if the reason they're denying the ADR is because as I posted in some other places, I have some retrolisthesis that another surgeon was concerned about. (My current surgeon doesn't think it's an issue). Because I'm so young, I'm just so scared that by the time I'm 50 I'll end up with a line of ruined discs and a neck full of metal from the adjacent segment issues with fusions.

Instantly denied on the peer-to-peer review, in case anyone is wondering. The reason stated is that I have disc damage at multiple levels (even though only one is a surgical case right now).