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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


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  #1  
Old 09-26-2011, 01:55 PM
Merlinus Merlinus is offline
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Default Aetna denied 2 level ADR

Received word at the 11th hour from Aetna via my doctor that they will approve a single level ADR only. Surgery was to be tomorrow 9/27/11, and they called the doctor friday 9/23/11. I've tried to discuss with the doctors staff and with Aetna - they make it their business to stonewall you. Now the doctors office has to reschedule surgery and resubmit for 2 level fusion.
My question to the doctors office was why can't I pay for everything over and above what Aetna won't cover? I can go after Aetna on my own after it's all done, right? The doctor said they don't have a problem with it but the hospital will bill Aetna for everything, period and the Aetna can deny the entire operation!? I'm scheduled to see the doctor 9/29 to discuss.

My company healthcare administrator will hear about this debacle. I work in the insurance industry, if we gave someone the kind of treatment that I've received I'd be hearing from our president's office having to explain why we PO'd our policyholder! We don't like those emails and do al we can to avoid them.
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8/2011- Cervical MRI report:
C5/C6: broad based posterior disc osteophyte complex causing thecal sac compression & cord flattening. Moderate/severe canal stenosis 9mm & bilateral moderate neural foraminal stenosis.
C6/C7: broad based posterior disc osteophyte complex w/ a small component eccentric to the rt causing moderate rt neural foraminal stenosis & mild lt neural foraminal stenosis. A moderate canal stenosis of 10mm.
On 10/18/11, two level C5-C7 ADR completed.
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Old 09-26-2011, 09:15 PM
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MeggieLynn MeggieLynn is offline
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Can you see if your doctor will submit it for an ADR at C5-6 and a fusion at the lower level? I thought Aetna was supposed to be ADR friendly - they might go for that. The problem is with having multi-level DDD. They might even consider a hybrid to be experimental. Most health plans in this country will not cover multi-level ADR and they are very specific about it in the plan language. They generally do not deviate from what is written in the SDP - Summary Plan Description. Good luck.
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*C4-5 and C5-6 Mild & moderate posterior broad-based disc bulges w/small posterior end plate osteophytes, mild spinal canal stenosis.
*C6-7 Broad-based posterior disc bulge w/small focal posterior central protrusion mildly indenting the anterior thecal sac, no canal or neural foraminal stenosis.
*SI Joint issues, Fibromyalgia, Chronic Myofascial Pain, Neurogenic Thoracic Outlet Syndrome
*Tx's-PT, 2 ESI's Interlaminar & transforaminal, 2 SI Joint steroid injections, Failed LBB for SI Joint
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Old 09-26-2011, 10:42 PM
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laid up doc laid up doc is offline
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"Aetna considers the use of hybrid fusion with artificial disc replacement experimental and investigational for the management of back pain, spinal disorders, and all other indications."

Intervertebral Disc Prostheses
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US non-spine MD - laid up no more!!!
had recurrent annular tear L5/S1, failed everything
M6L done 10/19/11 w/ Dr Clavel getting back to my old self more and more every week!
laidupdoc@gmail.com if my PM box is full

The content herein represents my professional thought and opinions in a general sense only; they do not constitute professional advice or services. if you need medical advice, please consult a licensed physician.
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Old 10-07-2011, 04:17 PM
Merlinus Merlinus is offline
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Join Date: Sep 2011
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Cool Aetna to cover only single level ADR, (I need 2 level)

I finally received word from my doctor that Aetna has agreed to cover the first level ADR, even if I am having the second level ADR done at my own expense. I will work out appeals with/against Aetna after having the procedure done. It took some time to convince the doctor's office to do this as they were sure that Aetna would deny everything. They were finally convinced after several calls back and forth to them , myself and Aetna. My surgery is scheduled for October 18th. The doctor expects they will charge me under $5000 for the second level. Well worth it to me, even if I lose all appeals.
__________________
8/2011- Cervical MRI report:
C5/C6: broad based posterior disc osteophyte complex causing thecal sac compression & cord flattening. Moderate/severe canal stenosis 9mm & bilateral moderate neural foraminal stenosis.
C6/C7: broad based posterior disc osteophyte complex w/ a small component eccentric to the rt causing moderate rt neural foraminal stenosis & mild lt neural foraminal stenosis. A moderate canal stenosis of 10mm.
On 10/18/11, two level C5-C7 ADR completed.
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  #5  
Old 11-07-2014, 08:39 AM
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colorado babe colorado babe is offline
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There is a court ruling on here in favor of the client to get a two level ADR. You should use this in your appeal. I used it for my Tricare appeal and I won but the appeal was through an outside agency (third appeal) . Plus, I used papers on evidence based practices that show it is not investigational. Good luck. Lots of wonderful info and people on these boards that can help you with your appeal when the time comes.

https://www.adrsupport.org/forums/f4...pay-adr-12341/
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1998- Injured neck and back in USAF
2011 - Started experiencing Severe Symptoms, Migranes, numbness, spasms in legs and feet and sciatica.
Feb 2014 - Received upper Lumbar Injection - Severe Allergy to injection
Mar 2014 - MRI of Cervical and Lumbar, protruding disc in C3-7, Herniated Disc in L5/S1, placed on STD and FMLA )
July 2014 - Stem Cell Procedure performed
Oct 20, 2014 - ADR (MOBI-C) at C5-7 and Anterior Fusion at L5/S1 by Dr. Pettine and Dr. Techy
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