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Aetna has refused to pay my chiropractor for the past 6 month

jac929jjac929 Posts: 2
edited 06/11/2012 - 9:02 AM in Health Insurance Issues
Hello everyone. I was assaulted outside of a department store 18 months ago which injured my 4 lower spinal discs. I have made progress, considering that I couldn't move for the first 4 months without sobbing in pain. I used to be a very active woman who played sports and worked as an RN before the injury. With the help of my PCP, we finally found some medications that helped me function again. By function I mean: walk, cook light meals and attend water therapy. In the beginning, I was seeing a wonderful Chiropractor 3 times a week who helped me with exercises, nutrition and adjustments. By September, I only needed bi-weekly appointments. I also pay out of pocket for massages with a certified Neuromuscular Massage Therapist 6 times a month and recieve acuputure 2-4 times a month (also out of pocket). Out of the blue, a denial letter came on December 6th, 2011 which stated that "...as of July 17, 2011, your chiro treatment does meet the criteria as medically necessary, therefore you are financially responsible for any treatments after July 17. The bill was over $3,000! I appealed it of course, but despite a letter of neccessity from my PCP who also stated that I needed increasing pain medication without chiro treatment and notes from my LMT indicating that I benefit from the treatments after massage, Aetna has refused to pay. I sent 28 pages of documentation and medical studies, and questioned them WHY did they wait 5 months AFTER I recieved the treatment to deny my coverage? I thought that the new year would allow me to resume my visits, but they have refused that as well. I am so tired of having to fight for every single benefit. I am re-appealing but am not feeling very optimistic. Any ideas would be greatly appreciated. TY. BTW - I am trying to avoid having back surgery which would, at best, offer pain relief for a maximum of 2 yrs (Radiofrequency innervation). It stuns me that Aetna would approve an $18,000 surgery that only has an 18-32% success rate!


  • First I would get to the root of "why" it's not considered medically necessary. They will tell you if you are persistant enough, but you can't give up. Are they not seeing enough improvement? Or are they just missing a document from your referring phyisician (which really is a reason for them to deny), or mabye just that your plan only allows a certain number of visits per condition?

    I personally would get a prescription or referral from a pain specialist in the future. If they deny still based on that doctors recomendation, I would then request a peer to peer review.

    A pain specialist will carry more weight in saying that you needed this treatment, and in a peer to peer review it would require the insurance company to have the same type of specialist you have reviewing to medical records vs. an RN which is who normally would be reviewing your medical necesity claim.
  • jlrfryejjlrfrye ohioPosts: 1,110
    Most insurance companies only allow so many chiro appts per year. Did you reach your limit after the date that they gave you? Also your plan may only cover per calendar year which means if your last appt was in July, your policy will not kick in again until July. If you are unable to to get Aetna to pay the claims speak to the doctor and ask them if they will accept the insurance allowed amounts. This will reduce your amount you owe tremendously. At least by half. Since it was denied due to medical necessity the problem is more then likely the diagnosis code used. Find out what diagnosis codes were used on your claims. If the primary diagnosis on the claims is a diagnosis not allowed the claims will be denied as not medically necessary. For example if you have 3 diagnosis codes used on your claims and the very first diagnosis code on the claim in a diagnosis that is not allowed ( even though the other 2 are allowed) it will make the claim not payable. If this is the case then the doctor will have to send in corrected claims. Good luck
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