Aetna finally sent the last installment

[trkdoc714]

The battle began about 6 weeks after surgery with Aetna denying the initial claim due to "no evidence of conservative treatment".

I started work on gathering doctor's notes for every office visit, MRI and surgical procedures. I copied studies on ADR success rates v.s. fusion and submitted the appeal (about 1/2" thick).

Some success came after that in the form of the surgical bill and device cost. Back to the appeal process...

Second appeal was mishandled, misplaced, misfiled for a few months. After daily calls, it turned up. A supervisor promised it would be looked at immediately. Within a few weeks (the day after I started calling again) an investigator called for information. She called a few days later with more questions from the surgical consultant reviewing the case. A week later she called and told em that the appeal was approved for the most part. She didn't detail what wasn't reversed.

Aetna's notice of approval denied the 5 days in the hospital after surgery. I filed another appeal with a letter of necessity from the surgeon. I failed to include all of the documentation of the previous appeal. All they looked at was the letter. They denied it. No more appeals.

I began the process of appealing with my benefits department, sending them the disputed portion of the bills. Denied. Once again, I should have submitted the 1/2" original appeal. I back tracked and sent it in. Unfortunately it didn't arrive before the expiration date.

Ignoring this denial, I contacted someone in HR that reached out to the benefits group management. After a few weeks, they agreed to look at it again.

Finally, 22 months after the original claim was filed, the benefits rep called and said, and this is a quote, "Our medical board now understands your claim. They didn't realize the procedure was that invasive".

The final check came this week.

What a long, strange trip this has been.

[KanRunMo]

Congrats for hanging in there in your fight for your rights from the insurance company.

[trkdoc714]

Thanks KRM. I was okay with me footing the bill until I realized the people I was dealing with had just gotten laid off from an aluminum siding telemarketing company. Something about a person that couldn't spell ADR denying the claim irked me.

[Justin]

Bob, congrats! You fought the good fight.

[trkdoc714]

Bob, congrats! You fought the good fight.

Thanks Justin. After all is said and done though, it wasn't the good fight. It's the unfortunate fight. The entire process reminds me of the Grisham novel, "The Rainmaker". It's a good thing we have politicians on our side trying to give everyone this same type of coverage and treatment.........right?

Boy, this post is a lot shorter after removing all of the words I usually use to describe insurance companies.

[bigdogchief76]

Please feel free to use those words!

Grateful for you Bob. Never should have gotten to the point it did though.

[Cindylou]

All in all, at the end of the day, you won your final appeal and that is great news! Thanks for including us in your final victory too Bob! CL

[KBear]

Congrats Bob!

[Gilbert P]

Hey Bob

That is great news lets hope this becomes more common for us spine patients

Gil

[jss]

Bob,

Congratulations! Way to hang in there for two years.

Jeff