Aetna Denies Coverage Without Reviewing the Full Appeal We never received the results of the appeal by their self-imposed deadline, as promised. I called Aetna. The representative told me the decision of the appeal had been mailed to us. I told him we never received it and asked if he could inform me over the phone. He did. Denied. I asked if he could fax me a copy of the letter of denial. To his credit, he did. But we never, ever received the hardcopy we were told was mailed to us (even though every other Aetna correspondence reaches us without incident). Below is a portion of the fax with names blurred for purposes of privacy. The bullet points are telling.

Aetna Denies Coverage Without Reviewing the Full Appeal

We never received the results of the appeal by their self-imposed deadline, as promised.

I called Aetna.

The representative told me the decision of the appeal had been mailed to us. I told him we never received it and asked if he could inform me over the phone.

He did.

Denied.

I asked if he could fax me a copy of the letter of denial. To his credit, he did.

But we never, ever received the hardcopy we were told was mailed to us (even though every other Aetna correspondence reaches us without incident).

Below is a portion of the fax with names blurred for purposes of privacy.

The bullet points are telling.

Fantastic.

The problem is, in that long list of compelling bullet points of exhibits we sent you (including "letter of medical necessity" -- nice to know your insurance company is working for you) you didn't acknowledge the video we offered both as a physical DVD and then as a downloadable video even though we have proof you received both.

You also didn't acknowledge the letter from Miranda's primary physical therapist, who stated "significant developmental changes that occurred as a direct result of the hyperbaric treatments." That one is coincidentally and conspicuously missing from your list too. That same unreviewed letter stated "The advancements were not occurring this rapidly with traditional physical therapy services alone."

So to describe the partial list of what you received as "all available information" renders that statement a cross between an implausible oversight and a naked lie.

The overlooked evidence has been sent to you twice, via two different mediums, with proof of receipt each time.

Prior to this, I was almost willing to give Aetna the benefit of the doubt. It's an enormous company. I've worked for enormous companies and I know how layers of bureaucracy stymie otherwise well-intentioned individuals. But to stonewall the process itself then ultimately deny/ignore receipt of two of the most compelling pieces of evidence can be nothing less than premeditated.

Let's review:

Denial of coverage.

Extensive appeal sent certified mail, return receipt. Delivery confirmed. Return receipt returned. Aetna denies receiving the appeal.

In response, they offer a fax number which is cut off on the answering machine.

Refuse to accept e-mail of appeal. Fax number offered again.

Appeal faxed. Fax confirmed. Letter of confirmation promised in one week.

One month later, no letter of confirmation.

Phone call reveals no record of fax, which was previously confirmed.

Fax finally acknowledged.

No decision letter arrives by deadline. Ultimately call Aetna, which renders its decision by phone. Decision faxed as promised, but physical letter (supposedly already mailed) never arrives.

Decision methodically considers (supposedly) "all available information," but neglects to list two of the most compelling exhibits.

Here's my favorite paragraph of the denial:

Uh . . . yeah?

And your own representative told us if we could prove the procedure helped her, you'd probably cover it.

Do you know of another procedure that lowers CK levels? Please enlighten us and the medical community.

We also stated in our cover letter that lowering the CK level to normal preempted a $50,000 muscle biopsy which Aetna would have been obligated to cover. We saved Aetna tens of thousands of dollars by footing the bill for HBOT out of our pocket.

Below you can download the entire video Aetna doesn't claim to have seen (it's an extended version of the video on the Overview page). All of this was available to Aetna for months via physical DVD and online, 24 hours a day.

[Note: The end of the video describes Miranda as she is "today." At the time, "today" was November, 2008.]

Click here to download a higher-quality Quicktime (.mov) version (64MB).

Click here to download a reduced-quality Windows Media (.wmv) version (16MB).