Insurance won’t cover disk replacement

[armorandswordwilling]

Hello. I’m reaching out because I have a problem and I’m not sure how to go about it.
In 2012 I had a Discectomy and everything has been good up until the last year and a half.
The sciatic pain is back, and I can’t do the normal things I used to do in life, like even finishing a work day. I did over of year of PT, and had 2 injections, and was told my next option is surgery since nothing helped.
I had MRI’s, X-rays, meetings with the surgeon, set a surgery date and did all of my pre-op stuff.
Insurance rejected the claim, and the medical director had a peer to peer with my surgeon.
They still rejected it because they won’t cover the spinal area that I already had a surgery done.
My option is out of pocket pay for the surgery, which I just can’t do.
Right now I have them checking to see if a fusion would be covered, because I am desperate.
Do I have any other options to get this covered? I’m in disbelief that i can’t get a procedure covered, just so I can try to live a semi-normal life.
Thanks for any help you can provide.

 

[catholicfollower]

@armorandswordwilling You can ask your doctor to help you appeal the insurance decision based on the procedure being medically necessary. It doesn’t always work but it’s your best bet.

 

[armorandswordwilling]

@catholicfollower I just got the appeal form. I’m going to reach out to them before I send it out

 

[rozenliefde]

@armorandswordwilling Aetna and many other carrier's have their medical necessity guidelines online. Call and ask what Aetna Clinical Policy Bulletin they relied upon to make this determination? Also, ask what the physician reviewer's rationale was? Report back and I can translate insurance speak for you into laymen's terms. Don't file an appeal until you fully understand the basis of the denial. Good luck!

 

[armorandswordwilling]

@rozenliefde Thank you. We spent the majority of the night looking at all of my claims through Aetna for PT and injections. We have a record form when the I started seeing treatment for pain. ( May 22’)
We have docs we got from the Aetna website. We are going to do what we can to fight this. I thank you for your assistance. We are calling tomorrow so I will ask for that info and call back.

 

[broggyb]

@armorandswordwilling Can you share more about your insurance? Is it through your employer? ACA Marketplace? Medicaid or Medicare?

What was their specific reasoning and language used for the initial denial and peer-to-peer denial?

 

[armorandswordwilling]

@broggyb Thank you for your response. My insurance is through Aetna, through my employer. The language was kind of a blur after the surgeons office called to tell me about the peer to peer. It was on the lines that they won’t cover the procedure on the same disk that I already had the surgery on. Said the medical director was pretty adamant about this.
When they Aetna rep called me last week, she said I would be receiving a letter as to why they are rejecting it, and an appeal process.
I also called them today to have my wife added as an AC because she wishes to speak to them, and they are also sending me a dispute and complaint form