Aetna Health Insurance - Aetna Health Insurance denial of payment

Posted on Monday, November 22nd, 2004 at 12:00am CST by 23922407

Company: Aetna Health Insurance

Category: Business, Finances

I am retired from Texas Teacher Retirement System. I belong to the TRS-care insurance program and Aetna (Lexington, KY) is the third party administrator. I was diagnosed with breast cancer in July 2004 and had two surgeries. Aetna paid the negotiated amounts for those surgeries, hospitalization, surgeons fees, etc. My treatment was to be radiation for five-seven weeks, followed by medication. My radiation oncologist's office called Aetna and was told radiation was payable at 80/20%. I began the treatments in September 2004. By October 2004, looking on-line at my Aetna account, I realized they were not approving payments for the radiation. Upon calling Aetna, I was told my radiation was "experimental" since it was IMRT (high intensity modulated radiation therapy). This simply means the method of delivery is not traditional, but the radiation rays are "bent" to the shape of the organ being radiated. This is a great method for me since I have congestive heart failure and have an artificial mitral valve implanted in my heart. Traditional radiation for breast cancer can sometimes affect the heart and lungs, but IMRT is directed so that it does not touch those organs. Since IMRT has been an approved method of delivery for brain, prostate, and spinal cord tumors, Aetna will pay providers for treatment of those cancers. It has only been in the last couple of years that it has been recognized as beneficial to breast cancer patients, but apparently Aetna has found a way to keep from paying claims by claiming it is experimental for breast cancer. Even though Aetna originally stated radiation is covered, I now owe the doctor about $60,000 and have the matter on appeal with TRS and with Aetna. Aetna told my doctor's office that their recorded message that stated "receiving approval from a customer service representative does not insure payment of claims" negated their original approval. It is my opinion that "radiation" is "radiation" regardless of the method of delivery. Aetna knows I have cancer and need the radiation. The stress in waiting for the results of the appeal certainly hasn't helped my health any. Velma B


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