My wife has GERD/LPR, Crohns and colitis. GERD came on ~2 years ago and she needs TIF surgery, the GERD has become significantly worse.
Insurance is through large local government, it’s good, but deems this as “experimental/investigational/unproven”. The alternative surgeries are not reversible, and side effects can be severe, and recovery is much longer and more involved (Nissen, Nissen fundoplication, LNF). The alternative surgeries could also be an issue for her other health issues, given they aren’t reversible.
The specialist office seems very proficient with the claims/appeals and the end result was they suggest paying in full to the hospital to receive a bit of a discount, or we can search around for another insurer. They said this policy was not very “progressive”, but that Cigna has never approved this surgery with them according to her records. Aetna has had significantly more approvals, according to the rep.
Initial visit with specialist late Fall 2020 Denied pre auth ~new years Denied appeals 2/2021 and 5/2021 Cigna requested IRO Review and Release 5/2021 IRO just came back upheld/denied under “Investigational” as final
I have a couple questions/notes, but would appreciate any other perspectives:
I don’t have insurance, would we just be spinning our wheels to consider getting additional insurance that might not approve this? Is the IRO the final appeal we can make? Without getting an actual quote for us from the hospital, the rep said the last TIF out of pocket she found was about $15k. We can afford this, but it would be a large chunk of our savings. The longer this goes, the more apt we are to pay out of pocket. There’s only 1 more specialist “in the area” that’s viable, in another state, several hours drive vs <20 minutes. Am I missing anything?
Thanks for any feedback!
submitted by /u/notmomo1
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My wife has GERD/LPR, Crohns and colitis. GERD came on ~2 years ago and she needs TIF surgery, the GERD has become significantly worse. Insurance is through large local government, it’s good, but deems this as “experimental/investigational/unproven”. The alternative surgeries are not reversible, and side effects can be severe, and recovery is much longer and more involved (Nissen, Nissen fundoplication, LNF). The alternative surgeries could also be an issue for her other health issues, given they aren’t reversible. The specialist office seems very proficient with the claims/appeals and the end result was they suggest paying in full to the hospital to receive a bit of a discount, or we can search around for another insurer. They said this policy was not very “progressive”, but that Cigna has never approved this surgery with them according to her records. Aetna has had significantly more approvals, according to the rep.
Initial visit with specialist late Fall 2020 Denied pre auth ~new years Denied appeals 2/2021 and 5/2021 Cigna requested IRO Review and Release 5/2021 IRO just came back upheld/denied under “Investigational” as final
I have a couple questions/notes, but would appreciate any other perspectives:
I don’t have insurance, would we just be spinning our wheels to consider getting additional insurance that might not approve this? Is the IRO the final appeal we can make? Without getting an actual quote for us from the hospital, the rep said the last TIF out of pocket she found was about $15k. We can afford this, but it would be a large chunk of our savings. The longer this goes, the more apt we are to pay out of pocket. There’s only 1 more specialist “in the area” that’s viable, in another state, several hours drive vs <20 minutes. Am I missing anything?
Thanks for any feedback!
submitted by /u/notmomo1 [link] [comments]Read Morer/HealthInsurance