Second Level Appeal Denied

Aetna offers a second-level appeal process, in which we have engaged.  In addition to indicating the myriad of anomalies in the first appeal process (not the least of which is not acknowledging two vital pieces of evidence), we included additional evidence, new research studies and Aetna's own statement on HBOT.

Below is a portion of that statement, Policy Bulletin CPB-0172.  While it's in the context of autism, many of the symptoms and diagnoses perfectly correlate with Miranda's. 

Here's what Aetna acknowledges in the context of explaining why it won't cover HBOT:

"Numerous studies of autistic individuals have revealed evidence of cerebral hypoperfusion, neuro-inflammation and gastrointestinal inflammation, immune dysregulation, oxidative stress, relative mitochondrial dysfunction, neurotransmitter abnormalities, impaired detoxification of toxins, dysbiosis, and impaired production of porphyrins. Many of these findings have been correlated with core autistic symptoms. For example, cerebral hypoperfusion in autistic children has been correlated with repetitive, self-stimulatory and stereotypical behaviors, and impairments in communication, sensory perception, and social interaction. Hyperbaric oxygen therapy might be able to improve each of these problems in autistic persons. Specifically HBOT has been used with clinical success in several cerebral hypoperfusion conditions and can compensate for decreased blood flow by increasing the oxygen content of plasma and body tissues. Hyperbaric oxygen therapy has been reported to possess strong anti-inflammatory properties and has been shown to improve immune function. There is evidence that oxidative stress can be reduced with HBOT through the upregulation of antioxidant enzymes. Hyperbaric oxygen therapy can also increase the function and production of mitochondria and improve neurotransmitter abnormalities. In addition, HBOT upregulates enzymes that can help with detoxification problems specifically found in autistic children. Dysbiosis is common in autistic children and HBOT can improve this. Impaired production of porphyrins in autistic children might affect the production of heme, and HBOT might help overcome the effects of this problem. Finally, HBOT has been shown to mobilize stem cells from the bone marrow to the systemic circulation. Recent studies in humans have shown that stem cells can enter the brain and form new neurons, astrocytes, and microglia. It is expected that amelioration of these underlying pathophysiological problems through the use of HBOT will lead to improvements in autistic symptoms."

So studies show it works, anecdotal evidence shows it works, videos show it works, lab results show it works and in Miranda's case it's probably saved Aetna thousands of dollars in future therapies and medical procedures.

Aetna, at what point does a modicum of common sense enter the equation?  If not via a blanket policy, at least a case-by-case consideration of cost/benefit analysis?

On Friday, May 15, 2009 we received a letter from Aetna.  Our second level appeal had been denied.  (It's interesting to note they now acknowledge watching the DVD they claimed to have never received.)

We were extremely disheartened.  The letter makes it clear we are out of options other than a civil lawsuit (which we haven't ruled out).  The following has nothing to do with anything; it's simply therapeutic for me to post on the internet: