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Old 02-25-2014, 01:22 AM
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Kelly4ADR Kelly4ADR is offline
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Join Date: Jan 2014
Posts: 259
Default Phase one: Aetna Denied

I am tracking my insurance progress on this thread to hopefully give some insight to others...

I saw Dr. Wohns at Neospine Clinic in Puyallup, WA on Feb 14, 2014

He confirmed that I need a two level disc surgery at C5-6 and C6-7. He did not recommend fusion but recommended ADR. Explained how mobi-c is now FDA approved for two level cervical. Then I said "lets talk about insurance..."

His response was that his clinic was having a really good track record of getting ADR's paid by insurance. I asked him about a two level... He said that is a little harder but they are seeing it be approved. Worse case, Aetna will pay for one level, I will pay out of pocket for the second, but it would be under 15K.

Feb 14, the day of my apt was a Friday. The following Monday their office was closed due to Presidents day. On Tuesday the 18th, his office put in the request for the pre-auth for the two level cervical ADR.

The next day, Feb 19, Aetna requested a questionnaire be filled out by the surgeon. They filled it out and sent it back on the 20th, Thursday.

Today is the 24th, Monday. I received a call from my surgeon's office stating Aetna denied. On the voice mail she explained that they were prepared to do a peer to peer Appeal involving their surgeons. If that gets denied, she will send another appeal. I called her back to discuss, but was unable to connect with her today.

I ordered Laurie Todd's book on insurance appeals.

To be continued....
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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