Aetna's Denial of Botox for Migraine - Update

Teri Robert @trobert Health Guide
  • Last week, I wrote about the problem I was having because Aetna had denied payment for the Botox treatment I had in October. If you missed it, check out Aetna Denies Successful Botox Treatment for Migraines.

     

    In a nutshell, my first Botox treatment was in December, 2012. At that time, I was averaging 25 Migraine and headache days a month, which fit the criteria for chronic Migraine. Thankfully, Botox has helped enough that I'm now down to averaging eight Migraine and headache days a month. BUT, because that no longer meets the criteria for chronic Migraine, Aetna denied the claim for my most recent Botox treatment.

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    Quite a bit has transpired since then...

    The day I wrote that post, I also Tweeted it and tagged @aetna. It was retweeted by several people, shared on several Facebook pages, and shared via other social media outlets.

     

    Later that day (Thursday), Aetna's director of social media called me. She apologized for her staff not having followed up after asking me for more information on December 21. She asked for some information to add to what I'd written, and she filed an expedited appeal on my behalf. An expedited appeal has to be decided within 36 hours, excluding weekends and holidays, so she said that if she didn't get back to me on Friday, she'd do so on Monday.

     

    On Monday, my Migraine specialist, Dr. David Watson, sent me a text message that he'd been on the phone with people at Aetna for over an hour. The bottom line is that after he talked to several people and pleaded my case, they still told him that the were not going to pay the claim.

     

    Late Monday afternoon, the woman who had called me called again - with a response quite different from the response Dr. Watson received. She said that they would pay the October claim. She also said that there will be no problem with the claim for my upcoming treatment, which is scheduled for January 15. The other thing she told me was that they would be assigning me a "Migraine case manager" with whom I can work in the future.

    So, what does all of this mean?

    • Obviously, it means that I can quit worrying about the October treatment bill and the bill for my January 15 appointment.
    • It seems that patients may, at least in some cases, hold more sway with insurance companies than doctors do.
    • I don't know if it means things will continue to go smoothly after that.
    • It appears that social media such as Twitter can have significant impact and that we shouldn't underestimate it.
    • We don't know if the appeal decision means they're rethinking their policy on paying for Botox when it helps enough that patients no longer meet the criteria for chronic Migraine, or if it means they responded as they did because of the negative publicity.

    Overall...

    I'm very relieved and pleased not to have to worry about the denied claim and my next appointment. The question is whether it truly indicates that they're rethinking their reason for the denial and if other patients will get the same results.

     

    This experience has made me wonder how many other Migraineurs have had similar problems. If you've had a similar problem, please leave a comment below and let me know, regardless of what insurance company it was. I want to see how common this problem is and if we need to launch an advocacy campaign to resolve it.

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    Live well,

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    © Teri Robert, 2013
    Last updated January 8, 2014.

Published On: January 08, 2014