Sunday, January 1, 2012

Happy New Year Aetna Members

This was recently posted as a comment under an older post.


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."

10 comments:

Maria said...

Awesome!

Anonymous said...

Oh my god!!! Thank you so much for posting this!! I'm headed to Aetna website right now. I've lost 4 appeals to have them cover my surgery, but if they really will cover it now ... I could not ask for a better New Year's present!!

Maria said...

http://www.aetna.com/cpb/medical/data/700_799/0736.html

Here is the correct link

Anonymous said...

I'm the above anonymous comment. I called Aetna and my surgeon's office, and the plan right now is for my surgeon's office to resubmit a predetermination, and for me to file my final level of appeal (external review), just to cover all my bases. But, it looks like it will be covered, and I'll get on the surgical schedule!! (the only wrench that may be in this plan is that I may be pregnant. Why couldn't this surgery have been approved a month ago?)

aetna said...

Thank you so much for this blog and for being very kind towards the people who are joined to your organization. In fact, I can expect such king of thing only from aetna blog and its members.

Anonymous said...

Aetna just approved my FAI surgery. Year long battle and multiple appeals but the second level of my second claim was granted.

Anonymous said...

I am truly happy for all of you that the good news applies to. However, my daughter is 13 years old and in much pain due to FAI Pincur and labrum injury. The age criteria in the Aetna policy says she has to be at least 18 years old. I am calling Aetna tomorrow to see if they will cover her surgery but it doesn't look good because of the age restriction. She has been a soccer and basketball player and starts high school next year. Sports is something she loves and she can't wait to play in high school. She's had a tough end of her basketball season because the pain has increased. Any advice on how to deal with Aetna? There is no way she can wait 5 years in pain to get this surgery! Thanks for any advice.....

Susie said...

Anonymous, don't give up and don't take no for an answer. There are appeals, second level appeals, you can have your daughters surgeon ask for a peer to peer review. I can't imagine though that they wont cover it, although I can't believe it took Aetna this long to come around. Please let us know what happens. Good luck!

Anonymous said...

Has anyone received approval from Aetna for FAI that is over 50 years old? If so, how did you go about getting this approval since the requirements say you need to be between 18 and 50.

stuart said...

http://www.youtube.com/watch?v=hoEifiovQ_s