I Beat Cigna!!!!!

[skmcpher]

I haven't been on this forum in a while but I just had to post here to give other people out there hope... I got a letter today from Cigna approving ADR at C4-5! I have spent the last two years of my life fighting with Cigna over this and I have finally won!

As a brief recap, Cigna denied authorization for the surgery for the first time in January 2010. I elected to have a fusion instead at C6-7, but that didn't help and less than 6 months later I was diagnosed with a grade 4 annular tear and concordant pain at C4-5. In August 2010 Cigna denied authorization for ADR at C4-5, stating it was experimental. I wasted months appealing to Cigna and lost, then I had an Independent Medical Review through the State of California Department of Insurance. I lost in January 2011. I spent that whole year waiting and hoping that Cigna would change its medical policy on ADR, but to no avail. I started researching having the surgery done overseas and started saving the money so I could go to Barcelona to Dr. Clavel, but it was going to take a long time to get all the money together. In January 2012 Cigna denied preauthorization again, and I decided to appeal again, and I bought Laurie Todd's books for advice.

I think what won my appeal for me was the fact that in each of the four denials, Cigna used medical directors who were not competent to render a decision on spinal surgery. The first denial was by a doctor who was either a psychiatrist, an internist, or a general surgeon (and I can't be sure which and neither can Cigna); the second was by an orthopedic surgeon who did not appear to have any expertise whatsoever in spinal surgery; the third was by a pediatrician; and the last was by a urologist.

I can't post a copy of my appeal letter here because it is way too long, but I wanted to let anyone out there who is going through this to know that it really is possible to win on appeal and to keep fighting! Also, I urge you to check up on the qualifications of the medical directors denying your care because if your insurance company is using incompetent doctors to deny your care, they could be breaking the law. So research those medical directors and if they are not qualified to practice spinal surgery, throw that back at your insurance company and threaten to sue for bad faith!

I want to thank everyone here for your support and I wish everyone out there still waiting for insurance approval the best of luck!

[Jen93312]

That's great news! Your persistance is encouraging. So what is the plan now--do you have a surgeon and a disc in mind?

Best of luck,

Jen

[jss]

skmcpher,

Congratulations! We only get stories here like your on very rare occasion. Thanks for posting, as it will most certainly be encouraging to many in your situation.

Good luck with surgery. Please update us on that too.

Jeff

[Shay]

Congratulations!
We also realized that the doctor making the decision on our appeal was incompetent to judge. He was in private practice 10 years ago for knee and hip surgery. Hardly qualified to make a decision for spinal surgery. We won the appeal for fusion, butdecided to go with ADR instead.
So DO check who is making the decisions that will effect your life!
Amazing job! Good luck on the surgery!
Yona

[skmcpher]

Jen,

My neurosurgeon who has been treating me for the past 2 years will be doing the procedure and he uses the Prestige disc. I really would prefer the ProDisc-C because I'm a little leary of the metal on metal design of the Prestige but I have to talk with my doctor to see if he uses any other discs and whether or not he would recommend them for me. I would love to have the M6 and wish it were FDA approved because I really like the design of that disc (which is why I was going to go to Dr. Clavel in Barcelona) but at this point I am so relieved to have gotten the approval that I'm not going to not have the surgery just because of the type of disc involved. An artificial disc is better than a fusion for me so I'm running with it.

I scheduled surgery for April 26 and while I am a little nervous about going under the knife, I am hoping that this will be a turning point in my long ordeal!

Again, I would like to express my gratitude to everyone who has posted on these forums because if it weren't for you I would not have known that there are so many people out there struggling with back and neck injuries, and I would probably not have heard of Laurie Todd and bought her books.

[Harrison]

Way to go, skmcpher! Glad Laurie could help!

[Lillyth]

Thank you so much for posting this. I have Cigna too, and you prompted me to check my denial letter which I got today. It turns out the person who denied my surgery is a urologist. I will definitely be putting that in my letter. Thank you so much for all your help!