Aetna Insurance – Neck Surgery, Denied Claim, Decision Final, No Bill?

Hello everyone,

This story is from Texas y’all, and I’m 40. I had two of my vertebrae fused in my neck to address a disk that was pressing onto the nerve running between them, causing constant pain. I did 1.5 years of physical therapy, pain medication, pain shots directly into my spinal cord, and I got pre-approval for my surgery. That original surgery request was still denied because I had not submitted the 1.5 years of PT records to them. I figured it wasn’t necessary since they had paid for it the first time…

I was able to appeal that and the hospital let me keep my surgery date while we worked it out. Don’t worry guys – the surgery fixed the pain and I’ve had a full recovery since then. Being able to turn my neck and participate in the holidays with my family again was absolutely worth it. The problem is the aftermath of the cumulative $60K surgery bill (across 13 claims) that was denied and still hasn’t been billed over six months later. All in network, pre-approved, etc.

I’ve looked at the Aetna explanation of benefit statements (EOB) and I’ve sent certified letters of appeal since I got the pre-approvals to make sure I didn’t miss any appeal windows. Here are the reasons listed in the EOB per the rules in the sidebar:

785 – No coverage for ineffective treatment. (I disagree.)

777 – Not covered in plan. (But it was pre-approved?)

PZ – No information available, check later. (This is the vast majority…)

W67 – Not covered as part of another service. Experimental, cosmetic, or exceeded number of allowed units. (This was blood and the screws for my fusion cage?)

U82 – Bill came from wrong entity.

Q1 – Duplicate claim. (It’s not)

Of the thirteen appeals, three were successful and have been processed. The others were all denied as the appeal being filed after 180 days per their policy, which I still can’t find anywhere in any document or website. Even though all 13 were sent in the same package to Aetna, the approval and denials came back in separate letters from the same person. The three successful appeals that Aetna approved to pay were the oldest ones, curiously enough. The last letter from Aetna said the decision was final. Is there anything else I can do and how much am I on the hook for if it was in network given the codes above? I had about $1K left on my out of pocket maximum (individual).

I appreciate the help and hope you guys are doing well.