Aetna Goes Insane Many good people have offered us support and advice. One suggestion was to pursue pre-certification, a process by which the insured petitions an insurance company to certify coverage in advance (an example would be to confirm a specific surgery will be covered before going under the knife). Pre-certification and appeals departments are two separate entities, and we're told the former trumps the latter. Two hours after we received the second appeal denial and were reeling from that bad news, Miranda's pediatrician called. Aetna had called her directly regarding our pre-certification application to enquire about the medical necessity of HBOT. Miranda's pediatrician told Aetna she had never seen such phenomenal progress in a disabled child (it's worth noting Miranda's pediatrician had never heard of HBOT for this purpose and was initially skeptical, i.e., she was converted rather than predisposed). Aetna gave her an authorization number for additional HBOT treatments! Authorization Number 6978-2873

Aetna Goes Insane

Many good people have offered us support and advice. One suggestion was to pursue pre-certification, a process by which the insured petitions an insurance company to certify coverage in advance (an example would be to confirm a specific surgery will be covered before going under the knife). Pre-certification and appeals departments are two separate entities, and we're told the former trumps the latter.

Two hours after we received the second appeal denial and were reeling from that bad news, Miranda's pediatrician called. Aetna had called her directly regarding our pre-certification application to enquire about the medical necessity of HBOT. Miranda's pediatrician told Aetna she had never seen such phenomenal progress in a disabled child (it's worth noting Miranda's pediatrician had never heard of HBOT for this purpose and was initially skeptical, i.e., she was converted rather than predisposed).

Aetna gave her an authorization number for additional HBOT treatments! Authorization Number 6978-2873

Chronicling a Battle with Aetna to Cover Hyperbaric Oxygen Treatment (HBOT) for Our Daughter, Miranda

My knees went weak. I choked back man-tears. I briefly considered changing the name of this web site.

Such a change, as it turns out, would have been premature.

We were authorized for 15 additional treatments. The pre-certification representative very optimistically explained that we could call after the initial 15 for additional authorizations.

We immediately called Charlotte Metro Hyperbarics and scheduled another round of 40, which Miranda underwent in June-July, 2009. We requested billing in 15-treatment increments to give Aetna absolutely nothing to complicate or confuse them. After the first 15 dives, we called Aetna for an additional pre-certification. Denied.

Apparently, of the 140 total dives Miranda has had over 14 months, Aetna believed dives 100-115 were the most medically valuable and worthy of coverage. That could be the only possible logic, other than their decisions are entirely arbitrary. Since the first option is nonsensical and the second is inept, I'm left unable to choose an appropriate insult.

The consolation prize was that we knew we were guaranteed reimbursement for at least 15 treatments, for we were staring at the irrefutable authorization number. We submitted for reimbursement directly from Charlotte, with their pre-certification number highlighted. Following is the pre-authorization letter, followed by their denial of coverage we received as soon as we returned to Connecticut.

But, of course, we were naive to think Aetna would actually keep its word. It was denied after the fact due to its "experimental nature."

The question is: Is this legal? Can an insurance company authorize coverage then deny it following treatment?

Suffice it to say, the name of the web site remains unchanged.

Before we move on, let's drink in some good news:

The Good News

Miranda had 40 more HBOT treatments. During that time she jumped for the first time, climbed up and down stairs for the first time, began to speak in 3- to 4-word sentences and is referring to her sister, Serena, by name (which is really cool).

Also: Miranda's lab work is now 100% normal. Her CK level had dropped previously, but methyl glutaconic acid was still a major concern as well as a number of other markers that remained high. Not anymore. Her geneticist described this development as "tantalizing" and told us he no longer needs to see her, as she technically has nothing wrong in that regard.

More universally, on July 10, 2009 (the week we returned from Charlotte) the House of Representatives unanimously approved the use of HBOT to treat traumatic brain injury (TBI) for veterans. It had already been approved for other injuries, but this is the first time it has been recognized for treating the brain. Congratulations to Texas Congressman Pete Session for leading this charge. Read more about it by clicking here.

Let's Review

Follow the full story via the below links, listed in chronological order.

Overview

HBOT Round One

HBOT Round Two

Aetna Loses the Appeal Application

Aetna Hangs Up on Me

Aetna Loses the Fax

Aetna Denies Coverage Without Reviewing the Full Appeal

HBOT Round Three

Second Level Appeal Denied

Miranda on the News/Aetna Reimburses

Aetna Corporate Review Denies Coverage