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So Mad! Cigna denied my SCS!

So I just got a letter today from Cigna, and they are denying my SCS implant! They have 2 reasons for this: they state that its not medically necessary for me (oh, like a healthy person would choose an scs) and they state that scs's for the neck is experimental and not covered by them. So ha, good luck fighting that... I am so mad and so discouraged and have no idea what now. The doc team is gonna appeal, but I wonder how that will go since they seem so firm on jow this is not covered by my plan...
Im mostly scared what else can be done for me if I cant get the scs. I have tried EVERYTHING except for a pain pump and Im working 25% at the moment.
Anyone have experience with getting a denial for the scs and then managed to turn it around with appeal? Anyone have any tips on how to handle this? I really would appreciate some help on how to handle tngs from here.

Thanks,
Victoria
Cause: car accident & genetics
Effect: herniations C4-7, stenosis, osteoarthritis, myelopathy, neuropathy
Non-invasive Treatment: everything under the sun
Invasive Treatment: 2 level ACDF, C5 & C6, May 2012
Moving Forward: SCS
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Comments

  • AllMetalAAllMetal Posts: 1,189
    edited 06/17/2013 - 2:43 PM
    I'm so sorry to hear this... how frustrated and worried you must feel. I'm glad your doc is going to appeal, it sounds like they are taking your pain and treatment seriously. If they loose the appeal, I hope they will continue to seek out treatment options for you. Best of luck to you.
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • that is so nice of you.
    Yesterday was frazzled, I felt like I completely got off track after getting the letter. My pain team is fantastic but the denial really worries me. We were ready to go as soon as this came through, met my rep from Boston Scientific, got my hospital, neurosurgeon, meds.
    I wonder what other things can be done if they refuse me this treatment... Pain pump? At 40?
    Well, I am gonna try to stay positive and not give up hope.
    Thanks again for your kind words.
    Cause: car accident & genetics
    Effect: herniations C4-7, stenosis, osteoarthritis, myelopathy, neuropathy
    Non-invasive Treatment: everything under the sun
    Invasive Treatment: 2 level ACDF, C5 & C6, May 2012
    Moving Forward: SCS
  • MsPixie
    Sorry that this has turned into another issue
    I sent you a PM
  • Ms Pixie,

    There are some things you can do while you wait for the decision from the appeal. One thing you can do is ask for all the medical records that went into the decision. Another thing your allowed is the actual policy regarding a scs implant, you might find they have not specifically spelled out the cervical spine. I had some similar on a rejection, while we argued it out for 6 months it turned out a MRI was missing, and that was missed on the doctor appeal as well. Good luck I hope this helps.
  • fxdwb69ffxdwb69 Posts: 31
    edited 06/19/2013 - 5:24 AM
    Victoria,
    This is just awful. Sure hope you can get something worked out. Your ins sound like a bunch of tools. Their commercial I see all the time annoys me too. Well anyways, I myself am so desperate that I would probably try to get the pump if they deny me. I'm still waiting to see if mine will be approved too.
    Adam
  • for very helpful feedback. The day I got the letter I was just frozen in schock mixed with anger.
    I have now talked to the insurance rep, read the policy word for word (tx Tamtam) and this morning talked to my nurse at the clinic. Yes Tamtam, the policy states only lumbar and thoracic scs is covered, cervical is experimental based on data from a study done with 11 (!) people! I happen to know a woman who has Cigna too and she got approved for cervical... When I talked to the rep they said that my doctor needs to proove that this is absolutely necessary for me to function and that the device is safe for this procedure. They have not gotten enough proof of that they say.
    So the story continues with an appeal and room for one more before the pnly option left would be to turn to the government for some health board to hear my case. The nurse said they are re-submitting again and adding more paperwork this time, and she warned me that this can indeed take some time now...
    I was ready to have this done June/July but now Im happy with waiting if there's a slight chance it can happen in the end.
    If they deny a second time, I will try to get my medical records and see what they have, thanks for that tip!

    As far as pain pump I havent been keen on that, but you're right Adam; if it can help me live a more "normal" life again, I might have to re-consider. The pain pump IS covered in my policy.

    Thanks everyone, its nice to have your support!

    Vic
    Cause: car accident & genetics
    Effect: herniations C4-7, stenosis, osteoarthritis, myelopathy, neuropathy
    Non-invasive Treatment: everything under the sun
    Invasive Treatment: 2 level ACDF, C5 & C6, May 2012
    Moving Forward: SCS
  • RickilalasRRickilalas Posts: 559
    edited 06/20/2013 - 8:14 PM
    Make sure you compare the cost and on going cost for a pain pump.
    Pumps are beloved to be more dangerous and more appointments to maintain then a scs this should be a no brainer for your insurance company's


    Wish you well
    Rick
  • Hey they denied mine too. Well not Cigna but my ins. which is through the military. I didn't get any other reason other than "command denied" which I think means it was denied here at my local base hospital. I have my monthly PM appt in the morning, I'll find out more then I guess...sucks!!!
  • Ms PixieMMs Pixie Posts: 154
    edited 06/27/2013 - 2:19 PM
    So sorry to hear that, it really freakin sucks!
    We find an opening, something that might give us a little of our life back. We get hopeful!
    And DENIED.
    When I got my letter 2 weeks ago, I was about to explode... Now my doc has appealed and I called the insurance company today. They still say its denied but wanted me to tell the doc that he should call them for a peer to peer talk.
    Dont give up!
    Im gonna keep on trying until there's no appeals left to use, but im hoping for a turnaround before that.

    Best of luck to you!
    Victoria
    Cause: car accident & genetics
    Effect: herniations C4-7, stenosis, osteoarthritis, myelopathy, neuropathy
    Non-invasive Treatment: everything under the sun
    Invasive Treatment: 2 level ACDF, C5 & C6, May 2012
    Moving Forward: SCS
  • MetalneckMetalneck The Island of Misfit toysPosts: 1,617
    Just a thought .... In your signature line you mentioned that this started with an auto accident. Have you attempted to seek coverage for the procedure approval from that carrier?

    D
    Spine-Health Moderator
    Welcome to Spine-Health  Please read the linked guidelines!!  (Click on Welcome to Spine-Health)
    My Story  - Click below
    http://www.spine-health.com/forum/discussion/44804/pain/neck-pain-cervical/long-and-winding-road
    I am not a doctor nor have I ever played one on TV.  Therefore any comments made are based on my experience.
  • read my description of my experience with the scs and you might decide you were lucky to have this denied. so many things can go wrong and with all the pain you feel now, it really can get worse. I am in much more pain since implanting and with 5 surgeries later to get the stimulator working in 4 months (last one yesterday) and one more major surgery needed, I probably would not have opted to get the implant. I understand the desperation to relieve pain, but when these implants don't work, the resulting scar tissue can make your initial pain even worse than it is now if you can phathom that. Turns out that implant failure is not so much a rare thing, but now I'm being told it is quite normal.

    I started a topic in this forum called "a cautionary tale to potential scs patients" which explains why I'm at this point. I whish I had done more net surfing of forums like this before electing to have the implant. I researched the technology but avoided reading peoples stories thinking only upset patients wrote. Turns out almost half of patients with these complain.

    Good luck.
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