Sent to me by a fellow hip friend:
Aetna’s assessment of FAI is archaic and asinine!
As you all are aware, our cause for UHC’s coverage of FAI was very successful including a NY Times article and many reversed appeals in favor of the patient. UHC along with other major insurers (BCBS, Cigna, Kaiser) now covers the arthroscopic treatment of Femoroacetabular Impingement.
Unfortunately, Aetna still has not caught up with the times. Many of our fellow patients have been successfully treated with hip arthroscopy and have been able to move on to enjoy active lives. People that are insured with Aetna are being discriminated against IF they also have a diagnosis of FAI. Aetna has taken the position that the use of the hip scope is unproven and/or experimental. This is absolutely ridiculous. It is very obvious that the bottom line is that it IS a covered procedure by the other insurers so how is Aetna’s non-coverage of this procedure accurate?
Aetna would rather have a young active patient become so disabled that their medical situation deteriorates to the point of needing a total hip replacement with all the associated medical risks and financial costs. Take the example of your typical patient. Young, active 30 year old Aetna consumer who is denied access to treatment for FAI. Based on Aetna’s opinion, the patient will go untreated for years UNTIL the patient requires a total hip replacement. Of course, doctors won’t typically do a THR on someone under 60 so this patient has to wait 30 years for treatment because of Aetna’s inaccurate and woefully pathetic position on FAI treatment.
Mr. Ron Williams (CEO of Aetna) when is Aetna going to catch up with the peer reviewed literature and your peers? When is Aetna going to reverse the policy so that your clients that need this surgery will have the same rights as patients that have UHC, Cigna, BCBS and Kaiser? When will Aetna decide that they would like the “A” in Aetna to equate to “Amazing” instead of “Awful’?
56 comments:
Suzi,
I was told by a fellow patient that Aetna is supposed to be reviewing their policy re: FAI in October.
Here is the PR person's contact info:
Media Contact:
Aetna
Cynthia Michener, 860-273-8553
michenerc@aetna.com
They had better review their policy - keep up with modern medicine!
I have been declined just this month!
Is there any headway on this.
I have appealed, my physician has appealed and i have contacted the state insurance commissioner. I can not understand how hip arthroscopy is not approved but a shoulder or knee scope is.
I've also had my surgey denied for FAI and was in complete SHOCK when told Aetna denied it! Come on Aetna!!!! Please see all the research from surgeons that specialize in FAI...the surgery is NOT EXPERIMENTAL!!!
My surgery was also denied after the doctor submitted a very detail background of why this surgery would greatly benefit me. PLease AEtna..get with the times and realize this surgery is NOT EXPERIMENTAL!!!!
I would say...start emailing the Public Relations for Aetna or calling:
Aetna
Cynthia Michener, 860-273-8553
michenerc@aetna.com
It can't be considered experimental when all their peers are covering it.
I was recently diagnosed with FAI. Surgery was scheduled for nov 17. Just found out Aetna is denying the procedure. We are appealing but very discouraged by what I am reading. It seems as though there is no hope. Any good insight.
I'm also wondering if anyone has had any success with this issue with Aetna. And did I read that all the other plans cover it?
This is a response from Aetna:
The date on our website is not the date that the update will be published, but the date that it will be discussed by our Clinical Policy Council. All updates have to go through a subsequent review, approval and implementation process. We expect the update to be published by the end of the year.
Should you have any questions or concerns, regarding these policies contact provider of services dedicated lines; Indemnity and PPO- based benefits plans 1-888-MD Aetna (632-3862) for HMO benefits plans – 1800-624-0756. Our Provider Service Representatives are trained to specifically handle any concerns you may have.
Also, for your convenience any future concerns or questions regarding our policies can also be faxed to us at 859-425-3379.
I just talked with Cynthia, the Aetna PR person. Aetna is reviewing this policy right now, so if anybody has any studies that support coverage, Cynthia said she'd get it to the lead reviewer.
I'm pretty new to all of this and haven't found any such articles, but thought I remembered somewhere (maybe on the Yahoo group) that somebody had put together a document of literary reviews to support coverage at another insurance company. Ring a bell for anybody?
We need to make as much noise as we can and provide as much information as possible to Aetna while the review process is happening.
Beth
Aetna update their policy to include open as well as arthroscopic FAI surgery to be experimental.
http://www.aetna.com/cpb/medical/data/700_799/0736.html
Aetna has reviewed their policy, and it hasnt changed, They approved all the submitted codes except the main unsubscribed hip arthoscopy code. The interesting thing is the Dr that reviewed my procedure and made his "educated decision for denial" Was a Hemotologist appointed by aetna. My Dr was furious and is appealing the decision. We will see what happens.
I was just denied coverage for hip arthroscopy (Dec. 8, 2010). I'll be 46 this week. I fell 2 1/2 years ago smack hard on right hip. Pain started a few months later, complained to my doc, got mri, showed bursitis, went to ortho and got cortizone injection--worked for a bit then stopped, two more injections and no longer helped. Went to different (better rated) hip doc and another mri showed tears and why coritzone didn't help and needs repaired. I'm a single mother with a full-time job and have to take care of my little bungalow and yard. What the hell am I supposed to do--wait until it gets so bad that need hip replaced? I have begun process of getting all prior doc/mri/x-rays faxed for surgeon office to also submit, but it's sounded to me like this may not help, based on other denials and that it's considered experimental. I don't get it, when an mri shows tears, and with arthroscopy, there's a way to have them repaired and sutured (not sure right term) so they can heal more naturally. I don't know of any other way to treat this besides taking a pain pill every 4 hours while tears get worse. I limp like crazy now and at the end of the day, the pain is so bad, I can hardly function, and at night in bed, it's awful and runs down from the hip all the way down leg and to the foot. Thank you for this post, and I will certainly be in contact with the aetna media person, etc.
I too have been diagnosed with bilateral FAI and also have AETNA and was told by my surgeon that AETNA has NEVER agreed to cover this procedure. Their review for 2010 just came out, and of course, they are holding fast to their notion that the procedure is experimental. Has anyone with AETNA coverage been able to push this through??? Does AETNA offer any other treatment suggestions other than injections and limiting uncomfortable activities??? How do they expect you to limit sitting or walking??? GRRRRRRR
AMA issued new CPT codes for FAI, Labral Tear Repair - now Aetna can no longer state there are no codes and it speaks to the fact that those procedures are NOT experimental
Good New FAI sufferers covered by AETNA. I just received a phone call 10 minutes ago from Dr. Byrd in Nashville, one of the fathers of the procedure-AETNA has agreed to cover my surgery!!!!!!!
If anyone has any questions, let me know and I'll be happy to provide as much information as I possibly can.
Yay-on my way to pain free days :)
Angel: Would you be able to elaborate on how Dr. Byrd's office got Aetna to cover it?
What is the new code if it was approved. I can't find it. I have had surgery because I was in so much pain I finally could barely walk. I was not able to work. I am appealing this with Aetna. They denied my first appeal, but I am not giving up. It is amazing how much better I am since my surgery. My MRI showed I had an anterior to posterior labral tear.
Angel - we need more information. Were you in an appeal process with Aetna? what does Dr. Byrd's office attribute the success to?
My appeal letter is being sent out tomorrow by my orthopedic doctor. I would be interested to know what these new codes are, and if medical professionals have been made aware of them. I should know somthing in 30 days. My original surgery date was Nov. 17, my hip has progressed and now locks up when walking on any type of incline. So frustrated...
David and Beth
Sorry for the tardiness in providing information but I've been out of the country for 2 weeks and heading back to Asia tomorrow. Needless to say 20+ hours on a plane each way, even in first class, does not feel good.
I've got a call with Dr. Byrd on 2/2/11 to schedule my procedure and I'll pick his brain about why my case was successful. To my knowledge, my case was submitted once and approved without any appeal.
Fingers crossed Aetna doesn't decide to throw some sort of whammy into the deal. . .
Thanks, Angel. My pre-op appointment is Feb. 3, so please post as soon as you can after your appointment. My OS's office will start the approval process after that appointment so any and all guidance will be greatly appreciated!
I was just diagnosed with this issue and have been told the following by the doctor that I was referred to:
Aetna will pre-certify the codes that are submitted. However, when it comes time to actually pay the claim, Aetna states that "the proceedure was not medically necessary". There is a disclaimer in all pre-certs that procedures which are not medically necessary are not covered. Thus, the patient is responsible for the entire cost of the procedure.
The doctor I was referred to told me they refuse to do the procedure on anyone insured with Aetna because it just isn't worth the hassle.
Can anyone tell me if Aetna actually has paid for the procedure?
I'm in the middle of planning my surgery. I do have Aetna, aren't I lucky? Anyway, I'm going into this under the assumption Aetna isn't going to pay. My guess is that my best shot at having them pay is after my surgery...
1. File a level 1 appeal, get it denied.
2. Use the information on the denial from my level 1 appeal and use it against them in my level 2 appeal. Have my level 2 appeal denied.
3. Use all the information Aetna provided me to build a strong case for when I have my case reviewed by a third party.
I've read so many stories about the doctors reviewing cases being Hemotolgists and pediatricians...I'm hoping I get that lucky. I've been saving documents and references already to help support my appeal.
I'm going to attack it like a lawyer. For every point they make for determining it not medically necessary, I'm going to prove them wrong.
I've already contacted the state insurance commissioner and my local congressman.
I'm on my second level appeal with Aetna for all of the claims they've denied for my physical therapy. They consider it not medically necressay...go figure.
I'll be damned if I'm going to let Aetna slide on this one. I've been contemplating contacting a lawyer to file a class action lawsuit. Aetna is out of line with their decisions as to what is "medically necessary."
I have considered a lawyer as well. How can they look at a 43 year old person that can barely walk and tell them no this is experimental. Who made them GOD
After years of cortizone shots for bursitis, an MRI showed a Labral tear. A new doctor scheduled me for arthroscopy on March 8. Tuesday, January 25, 2011 I got a call that the surgery would be denied by Aetna because it was considered by them to be experimental. Of course, I could pay for it myself. Since then I have been on the phone with Aetna, the doctors office, and my group provider, Texas Retired Teachers. It has been like hitting a brick wall. Please tell me how one person on the blog got it approved or where and who is your doctor? I have never been this discouraged.
FAI Sufferers to Sue Aetna
https://sites.google.com/site/faisuffererstosueaetna/
Angel,
There seem to be many here that are in desperate need of your help.
I too have a small labral tear and have just been denied on my peer to peer.
I am unable to return to my job (on my feet) until this is resolved.
Please tell us where to find the doctor that was able to get this approved or what he did to get it approved.
Thank you.
Hi Folks,
I'm sorry to say, but I have some very bad news. What Aetna has done is stated the following:
"BAsed on our current benefits information, procedure codes 29862, 29863, 2999, and 29861 for a participating provider are eligible for coverage if all other plan provisions and requirements are met.
Final determination of of coverage are made at the time of claims submission and processing. Payment will be based on the following:
1. Reported services
2. Prevailing fee
3. Our payment and clinical policies
4. Member eligibility at the time of services rendered
5. All other plan provisions"
So, what this means is they may have begun to change their approach a bit, but not in a good way. Instead of clearly denying me from the offset, they are sneakily "encouraging" me to have the procedure so that they can deny it after the fact. It would of course be denied based on number 3 and number 5 listed.
I will be meeting with my HR director next week as my company self insures with Aetna to see what they can do.
On another note, I am exploring the options of having the procedure done in Canada. Dr. Beaule, from University of Ottawa is one the the most prevailing surgeons in North America, along with Dr. Byrd and Dr. Philippon. The three of these surgeons teach all over the world, together.
I have heard that the cost of the procedure can half that of having it performed in the US.
I am truly sorry to have raised everyones hopes, including mine. However I thank Dr. Byrd's office for digging a little deeper into Aetna's "approval" to uncover their continuing deceit and denial of coverage to their participants.
I'll keep everyone posted on what I continue to find out.
Angel
Well my first appeal was denied this week. Aetna states they will uphold their decision that the procedure is experimental and investigational. So disturbing!!!I am a hairstylist and it is difficult to stand on my feet all day in pain.
Call Dr. Muldoon in San Diego. He had no problem getting approval from Aetna. My labral tear will be repaired on Monday morning at 7:20am.
His number is 858 278 3003.
I can't say enough about this man.
Be prepared for a lengthy wait to get to see him. Took me 3 weeks to get an appt. He scheduled surgery a month in advance and in that month received approval from Aetna.
Good luck everyone.
Yes Aetna will cover the laberal tear surgery, however they will not cover the fai debriment which created the tear. So if the fai is not addressed you may be having surgery again down the road to repair the laberal tear again. I would look into this before your surgery.
Angel: Can you elaborate on what your Feb. 7 post means to your case?
I'm trying to determine that if you have surgery that includes an approved procedure, like removing a cyst, but the doctor also removes the impingement and repairs the labral tear (not approved), does the FAI part negate the coverage of the entire procedure or just the part relating to FAI?
I'm willing to pay the surgeon's fees out of pocket, but I can't afford the hospital stay, anesthesiologist, operating room staff, etc.
I also have been denied by Aetna. Does anyone reading this have access to the Clinical Bulletins from UHC, Kaiser, or Cigna indicating they do cover this FAI surgery? Such info will be very helpful in my appeal to Aetna.
You wont get anywhere with aetna, I have had 3 appeals all denied. I however just had surgery July 1. It is amazing, I am pain free for the first time in 3 years. Today is 3 weeks and on this past Wed. I rode an excersize bike for 15 minutes. Recovery has been way better than I ever anticipated. I will be contacting aetna, to let them know how unfair they have been to people in this condition. Something so simple to hugely improve ones quality of life. I am blessed
Steel Blade,
Yes, I have them for my appeal except for Kaiser (which is an HMO--couldn't find them)). Google each company along with the words policy and FAI. They should come up. Takes a lot of research, but they are out there.
I've had verbal confirmation from Medicare that they cover 29914 and 29916 but can't find anything printable to include in my appeal. Can anyone provide that?
Aetna just redid their policy statement and we are in for this fight another YEAR! Something MUST be done and it won't happen with appeals.
Looks like Aetna has finally reconsidered their policy! Aetna posted this Clinical Policy Bulletin on 12/30/11 regarding
"Femoro-Acetabular Surgery for Hip Impingement Syndrome".
http://www.aetna.com/cpb/medical/data/700_799/0736.html
"Aetna considers femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome medically necessary for persons who fulfil all the following criteria:
* Diagnosis of definite femoro-acetabular impingement defined by appropriate investigations, X-rays, MRI and CT scans.
* Severe symptoms typical of FAI and compromised function, with duration of at least six months where diagnosis of FAI has been made as above.
* Failure to respond to all available conservative treatment options including activity modification, pharmacological intervention and physiotherapy.
* Aged between 18 and 50 years (clinical experience has shown that these patients are likely to gain the greatest benefit).
* Absence of advanced osteoarthritis change on preoperative Xray (Tonnis grade 2 or more) or severe cartilage injury (Outerbridge grade III or IV).
* Absence of joint space narrowing on plain radiograph of the pelvis that is less than 2 mm wide anywhere along the sourcil.
* Member does not have generalised joint laxity especially in diseases connected with hypermobility of the joints, such as Marfan syndrome and Ehlers-Danlos syndrome.
* Member does not have osteogenesis imperfecta.
Surgery for FAI impingement is considered experimental and investigational for all other indications."
I took my 17 year old to the doctor today and she said she needs this surgery but Aetna is still denying it. So here I go trying to go up the chain in Aetna to get this approved. The sad thing is my husband works for Aetna.
I too have been denied by Aetna two weeks ago for my hip arthroscopy. After reading the post back from 2010, seems that nothing has changed. They are still denying people who really need this surgery. I've been suffering for 3 years now and finally found a doctor to help me. All to no avail. What now?
Unfortunately, times have not changed. Was told by my surgeon today that Aetna WILL NOT cover this procedure. Aetna, you need to wake up. And you definitely lost a customer.
My son was just denied by Anthem BCBS - he is 19 and in near constant pain, unable to run, hike, golf, walk long distances, ride in a car comfortably for more than short distances, sleeps on a mattress on the floor of his dorm room as he cannot climb the ladder to his loft, can no longer ice skate (he was a hockey player), ride a bike, etc. etc. etc..............Anthem says "it's not bad enough". Ronda - you are right - times have not changed - it is not just Aetna. Perhaps the insurance companies prefer to pay for high blood pressure medicine, diabetes drugs and hip replacements as they condemn young people to sednetary lifestyles.
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