Long time reader of this forum, and have found lots of great advice and encouragement from peoples' stories here.
I am posting on behalf of a family member, Dale, who was diagnosed in June 2007 with a PFO after a series of TIAs/strokes. Luckily, none of the strokes caused long-term damage and he was put on Coumadin therapy.
After more tests with a neurologist and cardiologist, it was confirmed that Dale had no other causes for the strokes than the PFO (which is considered "large" in size). We discussed the PFO closure procedure, and were told that it might be an option at some point. Dale travels a great deal, sometimes internationally, so the idea of closing the hole made sense in hopes of preventing future issues.
In February 2008, he had another episode/TIA and ended up in the emergency room. Once again, he was lucky to have no permanent damage. His cardiologist recommended us to a specialist in PFO closures, where he went through additional tests (including blood screenings via a hematologist). Ultimately, by early July 2008, all four doctors--the neurologist, cardiologist, cardiovascular disease specialist, and hematologist) recommended the PFO closure procedure.
It was scheduled for next week. CIGNA (Dale's insurance provider through work) had approved the procedure, according to the doctor's office (although we never saw this in writing). However, yesterday we received a letter from CIGNA stating that they needed more information from the doctor in order to approve the surgery. We immediately called the doctor (who is out of town and unavailable) and the staff talked to CIGNA direct. We were told that the "request for more information" letter was sent out on Tuesday of this week, and that a "complete denial" letter was also sent on Wednesday, one day later! We have not yet received this letter in the mail, nor has the doctor's office. It is expected today or Monday.
We talked to CIGNA ourselves, and were told the precertification was denied because the PFO closure treatment is "not FDA approved and is considered experimental" and that insurance will not pay for it. We understood that with Dale's multiple strokes, one while on Coumadin, that he is a perfect candidate for it and that it is approved under these and other conditions.
So yesterday, the surgery was immediately canceled by the doctor's staff, and Dale was told to resume Coumadin, which was stopped last week in preparation for the procedure. We were told that the doctor would have to see the insurance denial letter and learn IF there is an appeal process or not.
You can only imagine our utter disappointment! Five days out from surgery, we learn that insurance says no and it is canceled in an instant. While Dale does okay on Coumadin otherwise, the February episode did show us that he can still have a stroke with the PFO there. We really wanted this procedure done and over with!! At the very least, we were hoping to reduce the chance of a future stroke.
Unfortunately, because this is a weekend, we are at the mercy of our imaginations! We want to assume the doctor will fight this, starting on Monday, and we can hopefully reschedule soon. But what if the doctor doesn't fight it? What if insurance rules here??
Does anyone have any advice for handling insurance denials on something like this? If the present doctor doesn't step up, would the next step be finding another PFO doctor somewhere else? An attorney to fight the insurance company??
I apologize for the lengthy tale here, and the somewhat scattered-ness of my thoughts. This really did blind-side us. Other family members were flying here for the procedure, and we really thought this would soon be behind us. It's terribly disappointing and upsetting to believe that perhaps insurance really does rule everything. :(
Thanks for listening and any suggestions you might have.