PFO Closure and Insurance problems

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JRER
New Member


Date Joined Aug 2008
Total Posts : 6
   Posted 8/2/2008 10:13 AM (GMT -7)   
Hello.
 
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.

JR
 

els
Veteran Member


Date Joined Oct 2005
Total Posts : 4031
   Posted 8/4/2008 3:06 PM (GMT -7)   

Hi JR, Wow! I am so very sorry for all your loved one and family is facing.  It is sad to have such a terrible illness then to top things off have an insurance company fighting against possible treatments.  I have been in this position with my illnesses (multiple sclerosis, and autonomic disorder).

Here's the deal, if Dale's physician believe's he needs this procedure then he will do the necessary steps with the insurance company to insure he gets it.  I would imagine he has staff & or a billing company who works with stuff like this often.  Bottom line is that insurance companys dont want to pay for anything that they dont "think or see as necessary".  Just remember that insurance companies dont have access to medical records so often times when you go to have a procedure such as this they will want to know why or show "medical necessity". 

Even if Cigna does come back and deny the procedure there is appeal rights that Dale has as a patient and ensured of Cigna.  On the denial letter it should outline his appeal rights and that is the way I would go.  Insurance companies have gotten too big and more money hungrey off of us the patients expense but we can fight them if we take the time to do so.

Please do keep us informed of how he is doing....take care

 


Elisha
Co~Mod: Depression
Moderator: Heart & Cardiovascular Disease
http://www.healingwell.com/donate


closed34
New Member


Date Joined Jul 2008
Total Posts : 4
   Posted 8/4/2008 3:20 PM (GMT -7)   
PFO closure is not covered under most plans unless a second stroke occurs while on Coumadin (and all other possible causes for stroke have been ruled out).  Since this appears to be the case in your family member's situation, I'm a little surprised that he is being hasseled.
 
I understand that ASD (atrial septal defect) closures are usually covered.  While this may be kind of sneaky (since PFOs are a kind of ASD, but not really) maybe a change of wording might be helpful.
 
If you can prove that Dale had a stroke while on coumadin, I think you have a good case and should appeal to the insurance company.  If he travels frequently, flying contributes to clot formation and he is at greater risk for more strokes.
 
I had the procedure done a month ago and received pre-authorization from our insurance.  We were told that this does not guarantee payment.  The doctor's office has had to provide supplementary documentation in some cases after the procedure was completed, but they eventually prevailed in all cases so far.  I understand your concern because we are not looking forward to a surprise hospital bill either.
 
FYI, I am 34 and had a stroke in April.  I had two prior TIAs.  Everything else has been ruled out.  I had a transcranial doppler done to see just how much blood was shunting from right to left through the pfo.  Even though my pfo was supposedly small according to the TEE, the transcranial doppler showed that I had the largest amount of shunting possible (grade 5), even at rest.  (In other words, blood was moving through my pfo when I was simply breathing like normal- no coughing or straining required to pass a clot across the hole.)  It turned out that my PFO was actually 1.5 cm., which is pretty big.  If I am hasseled by the insurance company, I plan to use the transcranial doppler test as documentation.  Also, in the two and a half months between the stroke and the procedure, I never had a theraputic INR with Coumadin (and I eliminated almost everything green from my diet).  They kept upping my dose until I was at 10mg daily when I went off for the procedure.  I felt like a sitting duck, so I was eager to get the procedure done.
 
I feel for Dale and hope everything works out for him.  He is lucky to have family members looking out for him!
 

JRER
New Member


Date Joined Aug 2008
Total Posts : 6
   Posted 8/5/2008 6:53 AM (GMT -7)   
Thanks for the support, guys. We are still waiting to hear back from the doctor. I guess the actual denial letter hasn't arrived (only discussed over the phone) so the doctor is waiting for that before talking to us. It's maddening though, not knowing what's next!

A Cigna case worker called yesterday, to "get more information." Very nice and asking lots of questions. She said she has no influence on the appeal but is "here to help." While we certainly want to be polite, I assume she is ultimately not our friend! :)

Closed34, I am glad to hear you have already had the procedure done. It sounds like your situation warranted quick action. Dale's PFO is considered "large" but I can't recall the size.

Again, I sure appreciate the support here. It is amazing how much it helps to know that others really do understand! Hopefully, we will have more news today or tomorrow. Just knowing that at any time another clot could cross over through that PFO....well, I guess I need to chill out and let the appeals process "work." There was someone else on this board (VN2000) who complained about Cigna Insurance denying a claim recently, but I never saw a follow-up with what happened in that case. I would assume that Cigna has indeed paid for some PFO closures before and they aren't all denied.

Thanks again, els and closed34. Your responses really help.

JR

VN2000
New Member


Date Joined Feb 2008
Total Posts : 14
   Posted 8/18/2008 11:21 AM (GMT -7)   
Hello Everyone,
 
I haven't been on this forum for a long time... But, I'm back.
 
I am still working with the hospital and their billing office to appeal my claim. They denied it 2 times already. It's quite frustrating as they'd assured us on the phone that we didn't require any pre-qualification and that the phone conversation prior to the surgery was enough.
 
As you can imagine, anyone who suffers a stroke, is mentally disturbed. I was extremely disturbed by the fact that I'd suffered a stroke at the age of 32 and wanted to do anything to ensure it didn't happen again. Thus, I had no patience to wait on the doctors office to make the calls and made some of the calls myself to ensure everything was going correctly.
 
The doctors office confirmed it and so did I that there wouldn't be a pre-qual letter and we were good to go.  Only to find out, 2 months after the surgery, and one expensive car letter that now we were SCREWED! And, at the mercy of the insurance company awaiting a final decision. I'm supposed to hear from them by September 1 and let's hope it's positive news!!! I can only pray!
 

JRER
New Member


Date Joined Aug 2008
Total Posts : 6
   Posted 8/19/2008 9:18 AM (GMT -7)   

VN2000, thanks for the update.  What a mess Cigna has caused you, and you are at their mercy.  It's just wrong.

Our doctor appealed the original denial last week, and has already received an "approval" going forward.  We received the "approval letter" from Cigna yesterday in the mail.  Of course, I don't trust them now, but we are hopeful that there won't be any additional issues.

While I have known for a long time that healthcare in America is in trouble, it isn't until it hits you or someone in your family directly that you suddenly realize this is real life!  Your situation seems almost criminal, in that you had the pre-qual letter and had every right to assume they would pay for the procedure.  To have Cigna come back afterwards and deny it...well, I just hope you get good news on September 1.  Please keep us updated.

I also am curious how you have been physically since the surgery.  Any issues or problems? 

Again, thank you (and everyone who replied) for the support and information.  Dealing with a stroke is bad enough, but dealing with an insurance company who doesn't care about anything but the monetary bottom-line is no fun either.

Best regards and hoping you get good news soon,

JR

 

 


VN2000
New Member


Date Joined Feb 2008
Total Posts : 14
   Posted 8/19/2008 5:23 PM (GMT -7)   

Hi JR,

I've been feeling much better. Of course, I'm more alert to my body now than I've ever been.  The stroke was a wake-up call.

I hope your procedure goes well.  I'm feeling fine. I haven't had any problems. I just wan't able to handle the PLAVIX after the procedure and had a bad reaction to it. So, I stopped taking Plavix and was put on Aspirin 325mg - that is it.

Please do let me know how it goes for you. I hope you have a speedy recovery.

 

 


VN2000
New Member


Date Joined Feb 2008
Total Posts : 14
   Posted 9/11/2008 8:09 AM (GMT -7)   
So, unfortunately for me, my claim got denied once again :(
 
I'm just getting so frustrated and stressed - it's unbelievable!

dbf
New Member


Date Joined Sep 2008
Total Posts : 1
   Posted 9/24/2008 6:58 AM (GMT -7)   

Hello,

I would like to know if there is a pfo device that has been approved by the FDA? I had a stroke and would like to have the procedure done, but my neurologist is telling me that I cant have it done until I have another stroke or a TIA. I'm taking Topamax for headaches and eye vision problems and Aspirin has a blood thinner. Any advice is appreciated


KT2008
New Member


Date Joined Nov 2008
Total Posts : 1
   Posted 11/5/2008 2:13 PM (GMT -7)   
Hello,
I read with interest the postings of VN2000. I too am battling with Cigna over my recent PFO closure. After a lifetime of aura migraines, I suffered a TIA (at the ripe old age of 32) last December. During my hospital stay, they found my PFO. Additionally, my MRI showed many "grey spots"--what the neurologists perceived to be signs of either damage from previous minor TIAs or all of the migraines. I finally decided to have the PFO closed this September.

Cigna preapproved me for the surgery--I spoke with them numerous times as did the team from my heart group. They are now saying that 1) I didn't get preapproval and 2) they don't cover PFO closures as the device used is experimental and not approved by the FDA for closure.

VN2000-have you gone through the appeal process? I am just starting mine. Also, what state are you in? I know these things vary state by state. I am ready to fight it out.
Thanks,
KT

Carlos512
New Member


Date Joined Nov 2010
Total Posts : 6
   Posted 11/8/2010 6:40 PM (GMT -7)   
This thread is sorta old. I have input for sure. I read it about JR and now I am in the exact same boat with a few differences: I'm 49 and had a stroke with a PFO that I had closed because that's what they said to do. They said I had what Ted Bruschi had in that I have no risk factors at all. Anyhow, my cretin Insurance company sent a denial letter after the fact saying they want me to pay the $100,000 bill. JR, if you still have issues I did find a lawyer who seems good, but I'm hoping not to need him. Respond to cpiper512@gmail.com if you need info. I am appealing mine, of course, but I need help because I've never been in this bizarre situation. I've rarely been sick.

Anyone out there have any tips?

cloverleaf
New Member


Date Joined Sep 2009
Total Posts : 1
   Posted 1/12/2011 12:42 AM (GMT -7)   
Hi Carlos. Have you contacted your state's insurance commissioner's office? Should be listed under the state's dept of commerce. Forget email, they get too many. Call them and they will assign someone to look into it. I beat Cigna on another type claim once with htem. Have all you facts and correspondence ready. Shoudl have been biiled as an ASD closure.
Sue
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