Attempting Reimbursement from Cigna
 

It's been quite the roller-coaster ride. We submitted originally, over 30 pages of documentation. It got sent to International, who said it would be paid. YIPPEE!

Then it turns out, that no, they won't pay. :bawling:

They tell us they need us to prove it was an emergency surgery, and we submit a letter from Dr. Clavel saying it was done on an emergency basis, and that had the surgery not been done, I would be in a wheelchair right now.

So then they deny us (again) based on us not showing medical necessity. (WTF?!) We sent them, literally, EVERY document they asked for, and more. So I'm failing to see how we did not show medical necessity.

At this point we have used up our two appeals. They are suggesting we do an IMR (which I do NOT want to do for reasons I can go into later, but not right now). We, of course, can file a grievance.

I'm wondering if anyone has any suggestions as to what to do at this point.

HELP?

I'm sorry you are dealing with this! It seems like insurance can throw out terms on a whim for basis of denial. In my appeals with Aetna, I am picking apart their terms and definitions. I have some articles and one court case where Aetna had to abide by certain guidelines for using "medically necessary". I don't know how the grievance process works for Cigna, but in my appeal I am requesting Aetna provide answers to a long list of questions I have on their determination process, definition of terms and actually give specifics on who determined and how it was determined "not medically necessary and experimental/inverstgational."

It shouldn't be, but it seems that it is, that if our DRs say its necessary, and the insurance says it isn't, insurance wins.

I wish there was a way for all insurance companies to have clearly defined definitions that are standard across the board. While your case is especially complicated, it just isn't right that some receive coverage and some don't.

Did you get in writing the approval? At my massage clinic, I have had sessions covered for clients who didn't even have massage as a benefit because someone at the ins. Co made a mistake and said it was covered. They were forced to honor it.

Hope this is somehow helpful.

Thank you for responding Kelly.

I will be calling in a few minutes to follow up, and you gave me some good insights as to what to ask for, which is definitely helpful.

My guess is that that will try to say the ADR was not "medically necessary" based on the fact that I "should" have had a fusion. (Six level fusion, are you kidding me?!?!)

Unfortunately, we don't have it in writing that we were getting reimbursed, but I'm going to comb through every single email I have from my husband. Sometimes, even just an email saying that so-n-no said something can be useful.

I will certainly keep this thread updated for anyone else who might be looking later on.

And, really, when it comes down to it, I have my legs. I have my arms. Everything else it gravy right? It didn't hit me until last week that I wouldn't just have ended up in a wheelchair. That was a C5-6 spinal cord injury. I would have lost most of the use of my arms too!

And that is something else I can push. I mean, it doesn't make sense that they would pay for a lifetime of care vs. ONE surgery that would make them not have to pay for ANY further care, right?

Thank you for the response, and I'll keep you all posted!

Guess what I found out today?

The fabulous Cigna representative (who really WAS fabulous, BTW) informed me that yes, they received the 35 pages of documentation we sent. It's just that... *drum roll* The last 12 pages were BLANK! And it turns out those were the pages with all the medical nitty gritty! Only no one let us know!

So, lesson to everyone - make sure they not only got your paperwork, make sure they can read EVERY SINGLE PAGE!

I will be re-submitting it BY MAIL this time, making sure with my own two eyes that everything is there! *sigh*

Cross your fingers for me!

ERRRRR! I feel for you! Please please keep me posted for every move made. Somehow it helps me when I'm not focused on my own battle...

Denial
 

Lilly,

The same, you are trying for reimbursement, I am trying for payment.

Of Course they denied, but I sent the Chief Medical Officer and the Appeals Board my 40 page Appeal.

Give them a wake up call, I need to get something done, this is getting worse. Did OT yesterday, and my back was killing me, I basically laid down all day.

Either the Health Care is going to implode, and we will have socialized medicine, or people will vote, and we can remove this mess.

Sorry for the Political Bent, but that is what we face.

:insane:

Oh man, Jerry, I feel ya! Trying to get them to pay in the first place just sucks. They try to tell you it's "not medically necessary", but I fail to see how a condition like this would be better served by taking away our mobility, and stressing adjacent levels to the point where *they* go and need to be fused too is of ANY help! :chainsaw:

We decided to contact an attorney. The same one who got the Cigna settlement that was recently posted about. I'm scanning in the documents to send them as we speak. I wanted to try the grievance first, but my husband is impatient. Plus, I kind of like the idea of someone else doing this for a change. :laugh:

I will keep you guys posted on that too!

And good luck Jerry! Here's a link to it, just in case it might help you! http://www.legacyhealthstrategies.co...ay-for-ADR.pdfhttp://www.legacyhealthstrategies.co...ay-for-ADR.pdf

Not medically necessary.

There's so much that could be said there in those three words that form a lie, that I assume they must say with a smile that even they don't believe in.

As if this was a boob job, hair plugs and a tummy tuck. These people are liars of the professionally trained variety on how not to feel havi or look other humans in the eye because they couldn't without having to avert their gaze.

Morbidity. That is unless you have cancer or heart disease, you are SOOL. Because they could get sued for not treating you. Here, they can bury you in their 'elective' determination.

Let's face it. You, as a back sufferer are their money machine. If you're fixed how are they going to make any money off prescriptions and endless PT?

Appeal Documentation
I returned from my European surgery and also received my Cigna denial. I am now preparing my appeal. I wonder if there are any attorneys that do this work on behalf of claimants/patients? Does anyone know if they work on a fee-based or contingency-based process? Does it depend on the artificial disc that is implanted, i.e. only certain attorneys work if the disc is a Prodisc versus an M6?

Can anyone share with me their appeal documentation? It seems like Jerry has a great package but I know your surgery is scheduled for this week so I would not impose. Is there anyone else that can share their info & process with me? Thanks.