Girl has blunt message for Aetna after her brain surgery request was denied

[n2doc]

(CNN)Cara Pressman sobbed in the big red chair in her living room. The 15-year-old tried to absorb the devastating news relayed by her parents: that their insurance company, Aetna, denied her for a minimally invasive brain surgery that could end the seizures that have haunted her since she was 9 years old.

"When my parents told me, I went kind of blank and started crying," she said. "I cried for like an hour."

Her friends had been lined up to visit her in the hospital for the surgery three days away, on Monday, October 23. Between tears, she texted them that the whole thing was off.

It was supposed to be a joyous weekend. Cara's grandparents had come to town to celebrate their 90th birthdays, a jubilant party with more than 100 family and friends crowding her home. The party did go on -- just with a lot more stress.

more
http://www.cnn.com/2017/12/11/health/aetna-surgery-denied-for-girl/index.html?sr=twCNN121117aetna-surgery-denied-for-girl0954AMStory

[Beakybird]

1. Those asshole insurance companies

[Alice11111]

35. It works so well having them as the middleman in our healtcare

system.


Suck, suck. They suck healthcare in both directions, money from the providers and from needed healthcare.

[democratisphere]

2. Aetna is part of the American Criminal Enterprise Healthcare System

that believes investors wealth is more important than a 15 Year old girl with seizures. F'ed up country.

[question everything]

3. I hope somone starts a "Go Fund Me" page for her (nt)

[Skittles]

5. I am sure insurance companies just LOVE medical gofundmes

[question everything]

7. Right. But if the goal is to help the patient, than use whatever means necessary (nt)

[Hav]

9. The insurance company already approved the more expensive standard procedure

It's not about a lack of funds. It's just that the doctors and patient would have preferred another less invasive procedure that doesn't seem to be as established yet.

[LanternWaste]

11. Laser ablation has been established for years.

Laser ablation has been established for years. Read the story... rather than pretending do have done so to better validate a biased narrative.

[Hav]

15. I did read the story

I didn't pretend to know anything. The newer procedure sounds way better. What I said was that it didn't seem as established yet and the article mentioned that larger trials are still planned and that the success rate shown by current studies is still not as high.

[Dustlawyer]

18. The insurance companies know that more people will choose NOT to have the invasive procedure

so they still save the money.

[mentalslavery]

26. and...if they approve an "experimental" one...they know those surgeries

are more likely to come with complications that might cost them more in the long run. Especially cuzs its a kid and there is the issue of long term care. So, I would surmise, money, is still at play in this decision...

[Dustlawyer]

40. Or there will be a huge influx of these procedures,

Some of which will have complications of course, but the sheer number of them will cut into the bottom line!

[mentalslavery]

56. true...its just sick!

[Alice11111]

38. Really, let the sympathetic people fund people in need

Instead of the insurance $$$ company.

Poor girl. So outrageous!!

If her drs will do the right thing and do it anyway, then she can sue the insurance company. No guarantees. However, I had to do that once when my daughter had to have emergency surgery on Superbowl weekend, and the insurance company would not approve it...until our people are back next week and we appoint a panel to review it....The Drs said, she can't wait.

The Drs went forward with the surgery. We were going to sue the insurance company together They said, we are willing to take a risk if you are.

After things were over, I sent the insurance company a Notice of Intent to File Suit. They paid immediately.

[Ferrets are Cool]

61. Ding, Ding, Ding We have a winna

[Hav]

4. To be fair

It's surely tough for the patient but the headline makes it sound even worse because Aetna instead approved a procedure that is more expensive but also more invasive. If it was greed alone, they could have approved the cheaper method and hoped it would do the job. And honestly, the argument "existing data shows it's effective more than 50% of the time" doesn't sound that great.

[marybourg]

13. Yes. You and I seem to have actually read the article, which makes

clear that the stumbling block is the status - at least by Aetna's standards - as "experimental", not the cost, since they approved a costlier procedure.

That characterization of "experimental" is not a new problem. It's been used for years to deny access to procedures that have not been thoroughly vetted, but which are promising, sometimes justifiably; sometimes not. This may be one of the "nots".

Perhaps it could have been addressed in an amendment to the ACA, if we had a caring, sincere President and Congress.

[grantcart]

44. Not a financial issue and the "selective editing" undermines credibility

[metalbot]

53. You should be ashamed

Reading the actual article and posting facts like this on an otherwise perfectly good insurance company bashing thread!

And for those bashing on the insurance company here, I'm not sure how you'd expect a different result if we had full on single payer healthcare.

[Ferrets are Cool]

62. I am guilty. Thank you for your diligence.

[kcr]

68. Wrong. It was greed alone.

They know damn well the patient won't choose the more dangerous, invasive and outdated option. This is a denial. Period.

[Ms. Toad]

73. I'd take minimally invasive and successful 50% of the time

over extremely invasive and much more dangerous and successful >70% of the time any day, especially since the minimally invasive procedure does not preclude having the more invasive procedure later.

I've also been on the denial end of a similar treatment (cost ~$500 v. 2 weeks minimum of hospitalization at ~$20,000). That particular treatment was being denied right and left, is now standard procedure, but at the time was one of two medical quirks directly impacting me that were (coincidentally) featured on ER.

Fortunately, I had very convincing doctors who got the denial reversed. I'll hope for the same for this person.

[CaliforniaPeggy]

6. Shame on Aetna. For shame.

I am appalled at their response, and their heartlessness.

[jalan48]

8. Insurance Company driven health care.

[WhiskeyGrinder]

10. At least the government wasn't getting between her and her doctor!

[Tanuki]

12. But Aetna's CEO will walk away with $500 million in the CVS deal.

http://money.cnn.com/2017/12/05/news/companies/aetna-ceo-cvs-payout/index.html

[hurple]

14. Obama's Death Panels

Strike again!

[irisblue]

36. Sarcasm emoji will prevent alerts.

Not all can recognize it.

[Alice11111]

39. Yesh, I learned that.

[world wide wally]

16. I suppose GOP Congress Critters are toasting the decision with some Dom Perignon about now

[Honeycombe8]

17. We need to get rid of insurance companies. Poor girl. Maybe a GoFundMe account? nt

[47of74]

19. I have an even blunter message for Aetna.

Two magic words. One starts with F. The other ends with U.

[bathroommonkey76]

20. Boycott CVS

http://www.latimes.com/opinion/editorials/la-ed-cvs-aetna-20171211-story.html

[benld74]

21. Aetna just bought out our insurance company

Coventry

Then

Aetna was bought by CVS

Eventually

All will be owned by 1

[Angry Dragon]

65. that is the plan

[Vinca]

22. That's a seriously stupid thing for an insurance company to do based solely on the dollars

and cents they will be paying for a person with a seizure disorder year after year after year. We expect them to be heartless, but they're usually right on top of things financially.

[grantcart]

45. You didn't read the article. They did approve a more established and more expensive option

[kcr]

69. One that is also more dangerous and outdated. They know patients won't chose it.

It isn't experimental. It says so right in the article, cited by researchers at the Mayo clinic for crying out loud. This is pure greed, plain and simple.

[grantcart]

74. ah approving a more expensive option is being greedy

at least you read the article

[kcr]

75. They remove the top of the skull

I'm not sure you did.

[grantcart]

80. Greedy is a pretty straight forward word, you should learn its meaning if you are going to use it.

The way that this news source edited the facts in the case was to make people angry about an insurance company because they wouldn't approve a procedure because of the costs when that is not true and if you didn't read the article you wouldn't see that fact buried deep in the story, and many of the people on this thread.

You, on the other hand, did read the article and continued to insist that, even though they approved another more expensive option that they are doing so for greed. Apparently you don't understand the word or have the ability to process the basic logic that the known facts provide.

At no point have I made any reference to the medical efficacy of one procedure over another. How can I without the patients' history and a current MRI? Perhaps there is a reluctance because she has shown a negative reaction to the medications that one procedure had over the other and that was the deciding factor. We can't know because we don't have the facts.

I seriously doubt that you are the best interlocutor about the medical issues involved because, let's face it, you are having trouble staying on point on this sub thread which is solely based on whether or not Aetna was "greedy" and whether the original article presented the facts in a straightforward way.

If I were to have a discussion about the efficacy of one option over the other I would wonder why you think that "removing the top of the skull" is a relevant fact because that procedure has, like many by-pass procedures, become rather routine. If I were to be the least bit interested in discussing medical issues over the internet with an anonymous person, and I am not, I would tell you that my brother had a significant drop in cognitive skills and the loss of the left side of his body ten days ago. All tests showed negative for either ischemic and hemorrhagic stroke and so they concluded it was swelling of the brain. The took him into emergency and with the first available surgeon removed the top of the skull. He almost immediately improved and after a steroid treatment brought down the swelling and replaced the skull top. And walked out his old self in 5 days with his some additional stitches on his head but no other negative side effect. But I am not bringing that up because the whole discussion of any medical issue has nothing to do with anything I wrote.

So try and stay on topic.

The topic is: Aetna approved a more expensive treatment option. Whatever Aetna's reasons for not approving the procedure money was apparently not one of them. There is no fact in the story that indicates that Aetna's actions were intended to increase profit to shareholders in any way, or as you put it, greedy.

The issue is settled if you want to divert into completely non related issues. In the meantime I will remember your moniker and realizing that this is a person that doesn't respect the facts of a situation in their arguments will give you a wide berth.

[PatrickforO]

23. Single payer. Single payer. Single payer.

Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer. Single payer.

Medicare for ALL Americans, NOW.

[Kimchijeon]

25. Can't say it enough... Agreed

[marybourg]

31. I'm a big supporter of single payer, but this is exactly the kind of decision

governments make also when they are the insurer. It wasn't greed; they were willing to pay for a more costly procedure. It was unwillingness to participate in an "experimental" procedure.

[Alice11111]

42. Yeah, but as someone said above, insurance companies

use that shield of experimental. We will pay to amputate your head, but those headache treatments are experimental.

[marybourg]

59. Yes, I said it myself, but it's also true that governments - when they are the single payer-

do the exact same thing. This is not one of the many problems single payer will fix. Guidelines need to be set thru legislation. The ACA is an appropriate vehicle for this, if we had a government that cared.

[Alice11111]

63. Yeah

[ecstatic]

54. How would single payer change her situation?

Aetna is willing to pay for non-experimental procedures. Medicaid and Medicare make similar decisions all the time.

[Marengo]

77. Single Payer systems dont pay for everything, all the time. Doesnt look like the UKs NHS...

Covers this procedure. To be fair I only conducted a cursory search, but I didn’t find a reference to laser ablation on the NHS website as a treatment for epilepsy.

[Hoyt]

24. While Aetna may be short-sighted, the procedure they approved has better outcomes, costs more, etc.

So, it's not a matter of Aetna saving money on this procedure. What they approved will cost a lot more than this procedure, but the traditional surgery also has better outcomes according to available studies.

One of the physicians quoted in the article appears to be paid by the company that manufacturers the equipment used for the procedure.

On the other hand, insurance companies move slowly -- as do physicians for that matter -- when it comes to adopting new technology with questionable outcomes.


According to the article linked in OP:

"While laser ablation [the denied procedure] has not yet undergone large randomized controlled trials, Van Gompel said existing data shows it's effective more than 50% of the time. He hopes the current clinical trial will show a success rate of 60% to 70% or better in epilepsy patients. Temporal lobectomies [the more costly approved procedure], he said, have a slightly better rate, of more than 70%."

______________________

One can also search other payers' coverage policies and one can read Aetna's coverage policy regarding this surgery for Drug-Resistant Epilepsy. There really is no good data to indicate that just anyone or facility wanting to provide the procedure is adequately trained/equipped to do so. United Healthcare also considers it experimental, needing more data and careful selection of patients AND providers.

In fact, it appears most of the studies for this procedure are funded by the companies that make the medical equipment, and stand to profit accordingly. I don't know which I would choose -- this new procedure or more costly, more invasive, procedures with better outcomes.



I do know this, Aetna -- or Medicare for that matter -- would be crucified if they denied the more costly procedure that has better outcomes for one that is less costly, and somewhat suspect. Here we are -- knowing nothing about the patient -- speculating that Aetna is wrong for questioning a new, relatively unproven procedure that is less costly and has worst outcomes.

As the Donald discovered, "who knew that healthcare is so complicated."

[lapfog_1]

27. I know another 16 year old girl who got the temporal lobectomy to stop her seizures.

and I can fully understand why this family wants to try the laser ablation.

Not only did her surgery not correct her frequent seizures, it changed her personality... short term memory loss, anger issues, general frustration with life. She will likely need help for the rest of her life.

[Hoyt]

29. I get it too. I also get Medtronic is behind much of the research and 70%

positive outcomes from the traditional lobectomy is better than the 50% so far proven in the laser procedure. It is truly complicated, I’m not sure which one I’d choose considering everything.

[lapfog_1]

33. laser ablation does not preclude future surgeries.

I had microwave ablation surgery on my heart almost 25 years ago now... so far, so good.

No arrhythmia attacks since my surgery. It was rated as experimental at the time as well... but my insurance paid most of the cost (there was an issue with paying for an extra doctor that was not agreed to beforehand).

[Horse with no Name]

71. There is a decision tree that is used

we sometimes do combinations of therapies. We’ll do right and left avkstins followed up by neuropace insertion, etc.
I’ve never had a laser case denied and moat certainly never had them push fur a t-lobe.

[Hekate]

28. KnR

[Luciferous]

30. This is why we need single payer!

[marybourg]

32. Please see my response, # 31, above. nt

[Hoyt]

34. Youd get the same issue over this very procedure with single payer.

Single payer doesn’t change the weighing of scientific data with this procedure, because the procedure Aetna approved is the higher cost procedure. I don’t think this is a cost based decision unless Aetna, United, etc., are concerned every person who can drill a burr hole — which is just about any doctor — will start performing this procedure because it’s cheaper and you make a lot more money in a few sessions than trying to treat the patient over time.

Facts are that the available data show the laser procedure has worse outcomes than the traditional procedure. And I know for a fact that medical device and equipment company sponsored studies are subject to manipulation. On the other hand, maybe the newer procedure avoids some of the negative outcomes a poster discussed about one of his friend’s children.

[Marengo]

78. UKs NHS doesnt appear to cover laser ablation either.

[Kirk Lover]

37. If the doctor wants to do this procedure and the patient agrees...then Aetna STFU !

[Hoyt]

46. You think healthcare is costly now, whether Medicare or not, let docs do whatever they want.

We tried that at one time and people were getting hip replacements while days away from expiring from health failure, cancer, etc.

[Soxderrube]

41. I will be done with Aetna on 1/1/2018

I have been stretching my prescriptions to the limit just to last until Medicare kicks in. I have 2 scripts that were listed as tier 1&2 in the Medicare booklet, last time I went for a refill they told me I had to pay 35% on my prescriptions $750 total cost per month for cost of $250 per month. When I asked them why so much they said the "rescue inhaler" was a tier 4 now and the hell with doctors orders that I am required to use 4 times a day. Also did you know that CVS Pharmacy is buying out Aetna, that is where Aetna prefers you fill your prescriptions. They got $125 from me for 3 months to pick up drug cost and I never was able to use it.

[Hoyt]

48. Unfortunately, you are going to run into the same thing with Medicare's drug plan.

[MizzM]

43. And speaking of Aetna...

Aetna is really on my S list. in 2016 my son broke his neck and is now a quadriplegic. It is unlikely he will ever work again. Aetna saw fit to place a lien on my son for $800,000 for some of the cost of his care because -- get this -- my son was not to blame. They know there is a lawsuit involved. To take $800,000 from my son who will never see money that he will need I think is unconscionable. Makes you wonder what insurance is for. Who would have thought an insurance company could do this?

[WillowTree]

79. Virtually all medical insurance will subrogate.......

.......against any payment made for the same charges by an "at fault" party. That's not an Aetna thing. Medicare and Medicaid subrogate against "at fault" party payments, too.

[Phoenix61]

47. I had breast cancer when I was 48

Everything turned out well but several years later the person reading my mammogram wanted me to get a breast MRI. Aetna denied paying for it. However, they would have paid for my sister to have a breast MRI because she would have had a sister (me) who had breast cancer before turning 50. Yep, can't make that shit up.

[DFW]

52. My wife had it at 49. That was her first cancer

Treatment took most of a year: 2 operations, chemo, radiation, and a month at a rehab spa.

He second cancer, last year at 64, was a super-deadly one, called "the murderer" in the clinic that treated her. Luckily, the specialist that spotted it saw it was in its initial stages, and pulled a few strings to get her treated immediately (usually you have to wait six months or more, by which time she would have been dead).

I'm very glad I didn't have to try and fight some American insurance company to pay for her treatment. It's probably the only reason we're not living in a tent and eating cat food. Here, the insurance even covered the month at the rehab spa, which is considered an integral part of cancer treatment here.

[roamer65]

49. In Ontario, Canada...

she would have been transported and admitted to Sick Children’s Hospital in Toronto. The surgery would have been done on schedule and her parents travel and lodging costs would have been completely covered by OHIP.

The cost for the surgery and hospital stay? Zero.

I know this because I know a Ontario family that had a similar scenario.

That is the power of single-payor Medicare, folks.

[DFW]

50. A.E.T.N.A.

American Enterprise To Not Approve

[Angry Dragon]

51. Corporations have only your best interests in mind

NOT!!

[tammywammy]

55. They approved a more costly surgery that has a higher success rate.

[Crunchy Frog]

60. And a higher complication rate because

It involves removing the top of the skull, and a good sized chunk of brain.

Even if it "works" it will still leave you with significant, permanent brain damage.

[Angry Dragon]

64. also more dangerous

[uponit7771]

57. **** AETNA WILL PAY FOR THE MORE EXPENSIVE HIGHER OUTCOME PROCEDURE *** (read the article)

[kcr]

76. *****PEOPLE ARE READING THE ARTICLE. THE PROCEDURE IS FAR MORE DANGEROUS**********

That's why Aetna knows damn well the patients won't have it.

[Turbineguy]

58. In the CVS-Aetna merger

the CEO is supposedly getting $500 Million.

There will be a lot of people who don't get brain surgery to pay for that. A lot of people will have to be made homeless too.

[yurbud]

66. Aetna made $2.3 billion in profits last year & paid CEO $17.3 million

Both of which is the reward for decisions like this.

[yurbud]

67. further proof that debate shouldn't be over single payer but whether insurance execs

should be in prison.

[Horse with no Name]

70. Laser Ablation is tricky to code

Some insurance companies want it coded a specific way.
It sounds like there is an error preventing an authorization.

[tavalon]

72. I hope they appeal

Insurance companies want you to be docile. Often these things are reversed on appeal.