Urgent Care Appeal

[bigdogchief76]

So, did some more research today.

I guess I'm posting this just in case someone reads it and finds an avenue to help them through an appeal process.

My plan allows me to do Urgent Care Appeals. I would beseech you to take a look at your plan before assuming you have this allowance; from what I understand it's not always the case. I found this out through research and then directly calling my company's plan coordinator. From what I was told, this has nothing to do with "urgent care" like after hours. It relates directly to Pre-Service claims like the one I got denied for.

Basically its "Urgent Care Claim (one where delay in making a decision could seriously jeopardize your life, health or ability to regain maximum function, or could subject you to severe pain in the opinion of your physician)" Ins company has 72 hrs to get back.

I can actually do these Urgent Care Appeals on the 1st level and 2nd level appeals.

My surgeon was in surgery today and tomorrow, but, I did put a request to have him approve (most certainly will do to the immobility issues and pain that I have; it's hard to understand how one little disc can cause this much injury)

I'm sure with all that is on this site, that this has been mentioned before, but, I did a Google search for it and did not see anything mentioned in any other forum or website, so, I'm hoping this might add to someone's arsenal of dealing with the crime syndicate aka insurance companies.

If this a duplicate forum, I apologize. If it helps even one person, then I consider it a success.

MB

[Justin]

Hi Matt, I do hope the "Urgent Care Appeal" works in your favor. However, I'm thinking that unless you have cauda equina (a surgical emergency related to the spine), most appeals wouldn't fall under this --> "one where delay in making a decision could seriously jeopardize your life, health or ability to regain maximum function, or could subject you to severe pain in the opinion of your physician." Fortunately, most spine issues are insidious and do not seriously jeopardize our lives (I know the way in which they are using this language -- more for procedures like cardiac catheterization).

Hopefully, your surgeon will help make the case for you and you can move forward with surgery soon.

[bigdogchief76]

I concur Justin.

I'm hoping that the "severe pain" bit might be useful. The AETNA rep today said it was ground's enough; she was probably just trying to make me feel better....can't blame someone that's just doing their job...

Thanks,
MB

[bigdogchief76]

So, found out today that AETNA decided to accept my appeal as an actual Urgent Care Appeal.

Just to clarify (I've had to do this 3 times with family members) this does not mean that they have approved surgery; it simply means that AETNA believes that I need urgent care (as does my physician and myself)

I was concerned that they would deny the urgent care appeal and make us go through the 15 day level 1 appeal.

I don't know what to read into it, but, I'm grateful I don't have to wait but 48 hrs for my answer.

MB

[KBear]

That is awesome! Praying that you get a yes.

[bigdogchief76]

Grossly misinformed yesterday.

AETNA treating appeal like normal 30 day appeal for pre-certification denials.

*SIGH*

Should have known better.

Not surprised; LBP is not life threatening unless cauda equina syndrome. So, I have a long road to toil through.

Such is life....

[KBear]

Sorry Matt, that sucks. I think one of the worst parts of dealing with the spine issues is the emotional roller coaster.

[Justin]

Grossly misinformed yesterday.

AETNA treating appeal like normal 30 day appeal for pre-certification denials.

*SIGH*

Should have known better.

Not surprised; LBP is not life threatening unless cauda equina syndrome. So, I have a long road to toil through.

Such is life....

Sorry, Matt. Hang in there buddy...things WILL get better.

[bigdogchief76]

....the emotional roller coaster.

You know, unless you have chronic pain, you truly do not understand that statement.

I consider it a comfort to know that there are people out there that have gone through this, are going through it, or are recovering from surgery.

Emotional roller coaster is the best analogy I can think of; thanks for understanding....

I was doing some maintenance on the PC today and looking at pictures over the past year and a half. It hurts my heart deeply to see pictures of my girl(s) and know that for many of the pictures taken I was either (A) NOT WITH THEM BECAUSE MY BACK HURT (B) Can't remember the picture because of this crap pain med I have had to be on for so long

I'm not one that gets depressed, but, I can see how easy it would be to get yourself mentally drained.

[Justin]

You know, unless you have chronic pain, you truly do not understand that statement.

I consider it a comfort to know that there are people out there that have gone through this, are going through it, or are recovering from surgery.

Emotional roller coaster is the best analogy I can think of; thanks for understanding....

I was doing some maintenance on the PC today and looking at pictures over the past year and a half. It hurts my heart deeply to see pictures of my girl(s) and know that for many of the pictures taken I was either (A) NOT WITH THEM BECAUSE MY BACK HURT (B) Can't remember the picture because of this crap pain med I have had to be on for so long

I'm not one that gets depressed, but, I can see how easy it would be to get yourself mentally drained.

You're in good company. We are all in this together and can truly empathize with your feelings above. I don't have kids (yet), but my only suggestion would be to take time each day to make make them feel loved. I know when I'm in pain, it can be easy to be selfish and not think "outside of my pain," as it can be all encompassing. You sound like a great Father...my hat is off to you.