The grounds for denial have been experimental/investigational and not medically necessary. The original request was submitted in January which was denied. This was followed by two appeals that were sent to Aetna, denied for the same reason. The last appeal was a third party reviewer who upheld Aetna's decision. I did include the Cigna court case, as well as every possible smitten of a hint of evidence. There are no more appeals as the external appeal serves as the final decision.
Next steps...I could hire an attorney. The CEO of my Dr.s clinic gave me the contact info for one. The problem with this is you can only sue an insurance company for the cost of the denied procedure (force them to pay.) you can not get reimbursed for attorney fees or any restitution above that. So, what do insurance companies have to loose?? It ends up costing the patient a lot in court costs to get them to pay, when if money were not an issue patients could just pay for the surgery. There is a documented win for the good of all patients if the ruling is against insurance, but as much as I want to push...it's a gamble, and a costly one. The Cigna case you are referring to Jeff was done pro-bono.
I have asked my Dr. to put in the pre-auth request for Aetna to pay for 1 level, and I will pay for 1. This is an option because 1level is acceptable to them and they routinely cover it. This I can afford at 16k, but Aetna could deny this as well, since their clinical policy bulletin states "ADR is considered experimental for patients who have DDD at more than one level" . So the request has been made and now we wait and see. This is plan B. I don't really have a plan C. Not yet anyway.
My Dr and his clinic may decide to do something on my behalf. He called in his CEO at my last appointment. I had the feeling they were in "gather information" mode. My Dr. Was very upset for me, saying things like "they just paid for this same surgery for someone else last week, they can't do this, it's illegal, we are going to hammer them on this, etc" (he also has a degree in law) I have no idea if they will take it up or not. My Dr. Went out of own and won't be back in until next week and I'll talk to him again at that point.
So that's my story, Learning patience has been my lesson. Counting my blessings and appreciating the small things ;)
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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
Last edited by Kelly4ADR; 08-19-2014 at 11:56 PM.
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