It's funny--I came over here to post this and I read a few of the back posts I've missed the last few days and this was on the front page. Sorry to ruin the Good!HMO vibes around here; this story? Not so favorable towards Aetna.
My boyfriend has severe, severe scoliosis (mainly because he has no left lung, so his spine is twisted all about trying to support his shoulders and rib cage with only half the stuffin' he's supposed to have). This scoliosis, in turn, puts pressure on his legs at really bad angles (he's completely duck-footed; his feet turn out at angles professional ballerinas would kill to be able to achieve). He also has severe pain in his knees and sometimes in his shins (in the muscles behind the shinbone, I believe).
Boyfriend has seen many, many spine specialists/osteopathologists (is that word correct?) and has been told, "We can prescribe you painkillers but your best bet is spinal fusion surgery" (that's the one where they
So the alternative offered was for him to receive maintenance chiropractic care. He found a chiropractor in his network (his job gives him Aetna; we live CT near the NY metro area), $15 copay per weekly visit. This works out well for him and keeps him relatively pain free (know what else helped? Getting a Sleep Number bed, no joke. He LOVES it). He's been seeing that chiro for about a month and has been singing the guy's praises non-stop.
As of this week, Aetna informed Boyfriend that they are no longer covering his chiropractic care. Boyfriend told me: Here's the problem. By their definition of what is medically necessary chiropractic, it's not. The pain management can be handled by pain killers as far as they're concerned. I've spoken with the doctor. Appealing it will get me nowhere because they are correct that I will not "improve" or be "cured" in any reasonable time frame. It is a long-term stabilization for pain management. Under their definitions, that is not medically necessary. They were not incorrect in determining that I will not improve, they were not incorrect in determining that it will not be a "reasonable time frame". Thus according to their policies and the plan that I have through **COMPANY NAME**, there is nothing to appeal. This is after the Doctor has already sent Aetna his own notes stating that it is medically necessary. Both the Chiropractor and **BOSS* said I should talk to HR first. So I am. Doctor is willing to continue a discount for me, but that's still $60/visit (his normal charge is $100/visit)and at $60/wk, I can't sustain that over a long period of time.
That cost would quadruple his cost of care (from a $15/wk copay to a $60/wk charge).
As he said, he's going to HR to see if there is anything that can be done, but he's not hopeful. Does anyone here know what we can do? I'm just on the verge of tears right now because I know he won't take painkillers daily as it will severely impair his ability to function--he can either not take the painkillers and suffer to the point where he can't walk, sit, OR stand--basically he can lay down in bed and that's IT, or he can take them and be too dizzy to do his damn job as well as too impaired to drive to and from his damn job as well as BECOME ADDICTED TO FUCKING NARCOTICS. This is so upsetting and the way HMOs treat people with chronic pain is HORRID (preaching to the choir, I know).
So uhm...can anyone suggest ANYTHING? He is waiting to hear back from HR but...yeah.
Thanks for reading my angry ranty twiddle-twaddle.
ETA: He spoke to the very nice woman in HR who is also a sufferer of chronic pain (I believe she told him lupus was the cause for her). She said it can be appealed but the chances that he will win the appeal are miniscule. Aetna basically has the law behind them because even though the doctor wrote him a note, since he'll never make a "reasonable improvement" or find a "cure" from a chiropractor, they're cutting off that service--and that's perfectly legal. :( *siiiigh* Looks like I need to find a good job that offers better insurance but, as a new teacher, I'm pretty much fucked too, heh.