Hello all, hope you can help me as I’m pretty much in a dark place at the moment.
For background, I’m a 47 y/o Aetna member (PPO) and Pennsylvania resident, and I’ve been dealing with fairly extreme shoulder pain over the last 6 months that has reduced quality of life (can’t lift things, can’t play with my kids, can’t rake leaves, carry a laundry basket, etc.). I also end my workday (which is luckily office-based) in agony from just using a keyboard and mouse all day. While I haven’t been in imminent danger of harming myself, I won’t lie and suggest thoughts of living like this were palatable.
I finally had an opportunity to see a surgeon who is in-network and has excellent outcome data etc. and who I’m very happy with. He did a number of studies (MRI, CT) and my shoulder is essentially shot – cartilage gone, cystic changes in the joint, etc. Rugby and football have not been kind to me, apparently. He’s recommended shoulder replacement surgery, and I actually had a second opinion who confirmed that’s really the only fix if cortisone shots and pain management are not handling it.
Here’s my dilemma: While this surgeon has admitting privileges and can have surgeries at two in-network hospitals for Aetna, neither are scheduling elective surgeries at the moment due to COVID. In fact, NONE of the hospitals Aetna has in the area are, so if I was desperate and willing to go to another surgeon just to get it done, it wouldn’t help.
My surgeon can hold surgeries at a local ambulatory surgical center, but its out of network. For now, for me to go there I would have to pay the full amount of the surgery out of pocket – Not something I can pull off. My only other option is to wait for hospitals to open up again and there isn’t an ETA (and likely will have a backlog of elective procedures when they do). My question is: Is there anything I can do with my insurance provider (Aetna) to get this covered given the circumstances?
submitted by /u/TheGrumpyGent
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Hello all, hope you can help me as I’m pretty much in a dark place at the moment. For background, I’m a 47 y/o Aetna member (PPO) and Pennsylvania resident, and I’ve been dealing with fairly extreme shoulder pain over the last 6 months that has reduced quality of life (can’t lift things, can’t play with my kids, can’t rake leaves, carry a laundry basket, etc.). I also end my workday (which is luckily office-based) in agony from just using a keyboard and mouse all day. While I haven’t been in imminent danger of harming myself, I won’t lie and suggest thoughts of living like this were palatable. I finally had an opportunity to see a surgeon who is in-network and has excellent outcome data etc. and who I’m very happy with. He did a number of studies (MRI, CT) and my shoulder is essentially shot – cartilage gone, cystic changes in the joint, etc. Rugby and football have not been kind to me, apparently. He’s recommended shoulder replacement surgery, and I actually had a second opinion who confirmed that’s really the only fix if cortisone shots and pain management are not handling it. Here’s my dilemma: While this surgeon has admitting privileges and can have surgeries at two in-network hospitals for Aetna, neither are scheduling elective surgeries at the moment due to COVID. In fact, NONE of the hospitals Aetna has in the area are, so if I was desperate and willing to go to another surgeon just to get it done, it wouldn’t help. My surgeon can hold surgeries at a local ambulatory surgical center, but its out of network. For now, for me to go there I would have to pay the full amount of the surgery out of pocket – Not something I can pull off. My only other option is to wait for hospitals to open up again and there isn’t an ETA (and likely will have a backlog of elective procedures when they do). My question is: Is there anything I can do with my insurance provider (Aetna) to get this covered given the circumstances?
submitted by /u/TheGrumpyGent [link] [comments]Read Morer/HealthInsurance