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Cigna Insurance and the linx procedure

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Posted 7/17/2012 2:08 AM (GMT 0)
I went up to Jacksonville last week to have the linx procedure done by Dr. Smith. I spent 3 days prepping for the surgery; blood work, pre-operative evaluation, pre-admissions, chest x-ray, etc. just to have my insurance deny the procedure the day before the surgery. Mayo clinic sent in the surgery request on the 3rd of July but it took Cigna till July 11th to give them a response which was the day before surgery. I appealed the decision and Dr. Smith went to bat for me with the insurance company but it was denied again today. I have an individual insurance plan with Cigna, so I am not sure if they are also denying people that are on group plans with them. The price quoted to me for the procedure out of pocket was around $25,000. I am going to contact Dr. Smith and see where to go from here but it looks like I will have to hold out for a while. I posted this just to give people with Cigna insurance a heads-up. Mayo clinic is also considered out of network with Cigna since January 1st of 2012.
Posted 7/17/2012 1:02 PM (GMT 0)
I am surprised any insurance is covering the LINX because it is so new. I figure it will be a while til it is covered. I think the only procedure covered for most plans is the Nissen. I dont know about the TIF. That is dissapointing news, though I am sorry.
Posted 7/17/2012 3:10 PM (GMT 0)
There are some insurance companies that are accepting the linx procedure at the Mayo Clinic. Dr. Smith even told me some people through Cigna were accepted but I am guessing they were most likely on a group plan through their work. I think the majority of people with individual health insurance plans will get denied when it comes to the linx procedure.
Posted 7/17/2012 3:53 PM (GMT 0)
From what I understand, Insurance companies use the vagueness of the literature to justify not paying. They also will create arbitrary standards for approving a procedure and will retrospectively review cases and decide that since a report wasn’t phrased perfectly they will not pay. The patient will have to take the case to a lawyer if/when they deny it again.

I have heard of patients having the pre-approvable from the insurance companies for a procedure only to have the bill turned down after the fact.

I do not have an answer but I am thankful that so far our health insurance has cover the many procedures and surgeries my husband has had over the years.  His last surgery in 2010 cost over $100,000.00 and having to cover about $ 6,000.00 was a strain for us.

I truly understand peoples fears and frustrations re health insurance.

Kindly,

Kitt

Posted 7/17/2012 7:23 PM (GMT 0)
Stkitt what kind of lawyer is best when dealing with medical insurance claims? I am looking for someone in the state of Florida.
Posted 7/17/2012 7:25 PM (GMT 0)
I just don't understand how these insurance companies get away with denying treatments that have been FDA approved by saying they are experimental and are not proven to work.
Posted 7/17/2012 8:02 PM (GMT 0)
I think that the insurance companies are of course thinking of it in money terms....cover what has "worked" the longest because if they are going to pay for something, better use the money for the Nissen which has been around longer. The LINX may work better, but in their eyes, it is a risk, and of course they do not want to risk paying for something newer. That is why when there are new drugs available, a lot of insruances will wait years before they cover them. So maybe after, I don't know, 5 or 10 years then maybe they will cover the LINX......great.
Posted 7/17/2012 8:21 PM (GMT 0)
For those that want to appeal the insurance's decision I found a site that will give you a guide to the appeals process. It is with the patient advocate foundation and they have a ton of information regarding this.
www.patientadvocate.org/resources.php?p=36
Posted 7/17/2012 9:18 PM (GMT 0)
For those who are wondering what code the Mayo Clinic is using for insurance it is:

43289: Unlisted laparoscopy procedure, esophagus
Posted 7/18/2012 1:10 AM (GMT 0)
Johnboy: I am so sorry to hear about that. Hopefully you can appeal it and get your procedure done.
Posted 7/18/2012 1:14 AM (GMT 0)
Hey thanks Carrie.
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