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Appeal process is beginning, but I am in incredible pain!

13

Comments

  • You can call Aetna directly and confirm their coverage for 2-levels.  Just a friendly tip in case the surgeons office pushes back on resubmitting your request.  I've been down that road with a surgeons office manager therefore my advice is to do your due diligence check.  I have UHC and they began coverage as of April 1, 2015.  Would have thought that the other 2 national carriers would follow in their footsteps sooner than later.
  • sara.gsara.g CaliforniaPosts: 45



    sara.g said:

    Txpenelope!!!! Have your surgeons office resubmit!! Aetna covers 2-level ADR NOW!! I literally got through all my appeals and went through Extermal Review with the board of insurance and got a denial. On July 8th, Aetna changed their policy on 2-level ADRs during their yearly review. I hope this helps you!! 

    Where can I find documentation of the July 8th policy change??? Need asap. 

    Your surgeon just has to resubmit the surgery for approval 
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  • sara.gsara.g CaliforniaPosts: 45
    Actually if anyone does find proof on paper that Aetna covers 2-level replacements please let me know where to locate this. I'm trying to facilitate my surgery and so many people involved don't believe Aetna covers it now, despite that I have a pre approval. I need to send them proof the policy had changed!!!
  • SongJinSSongJin Arizona Posts: 287
    Wow congrats I hope you get it approved! I'm super jealous--I had my fusion back in March and I'm still doing really poorly. I think I would have had a much better recovery if I had won my ADR case. 
  • Sara - call the number listed on the back of your insurance card and ask them for the documentation you need.  I would have thought a pre-approval letter would suffice.  I just found that Cigna is covering 2-level cervical ADRs now (effective June 15th).  However, I still can't locate any documentation on the internet to help you with regards to Aetna.  Keep us posted.  
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  • I was on the phone with Aetna for hours for this. They admitted that there was a policy change on July 8th but the policy directive has not been updated in their system yet.   They said it should be in early October. Search for CPB 591 on the Aetna website. Look at the date on the bottom of the last page. Current one states Next review date is 7/8/2016 & last review was 11/20/15. Watch for that date to change.  My surgeon 's assistant said she will have to resubmit then. 
  • Beach girl , I'm curious how much you know about Cigna. I had  a 2 level ACDFP 4 years ago with BCBS and now looking at needing another ... But don't know the extent yet but so fa Cigna has declined my MRI after requiring a neuro exam which I had on top of an EMG. That shows nerve compression below my plate, and they continue to deny an MRI after 2 appeals and radiculopathy and dizziness. ... Sooo I will pay for MRI on my own :-( 
  • Hi Doodles,

    What is the reason they are denying an MRI?  I think it depends on each individuals policy and the reason the doctor ordered the test.  I'm not an expert on insurance, just did a lot of research on insurances last year prior to my 2-level cervical ADR surgery (which was a fiasco).  UHC was awesome but one of the surgeons I was considering was a pain in my butt trying to get the office manager to submit my claim for coverage.   Long story short, I switched surgeons due to the multiple problems encountered with their office staff.  Since my surgery, I've been watching to see when Cigna and Aetna start covering this procedure b/c I think there are a lot of patients that could benefit from this option vs fusion.  MRIs are expensive!  
  • SavageSavage United StatesPosts: 7,385
    hello txpenelope !
    welcome to spine-health
    please click on link for helpful information!
    Sue
    Honorary Spine-Health Moderator
    -------------------------------------------------------------------------------------------------------------------------
    Please read my medical history at: Medical History

  • sara.gsara.g CaliforniaPosts: 45
    Songlin I'm very sorry to think of that, although I know now that many people find relief with fusion as well. To everyone, I'm in my hospital bed 16hrs post op via this same policy change. I hope this gives hope. Also, surgeons find it very helpful when you reassure them that if health insurances short change them for their fees, overage payments may still be made just as with any other bill. 
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