PFO Closure and Insurance problems

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

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!

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!

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.

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