Insurance coverage update

[Guest guest]

Hi everyone,

Sorry for the change of subject... I wanted to post an update on our battle for

insurance coverage, as it might help someone else.

Aetna did decide to cover the 140 sessions of HBOT that we have done previously.

We then had a corporate appeal, wherein there were 14 representatives from Aetna

(9 doctors, executives, lawyers) and Dr. Harch presented the case that HBOT has

helped Miranda. We are working on a transcript of the hearing if anyone is

interested.

We have based our appeals on a paragraph that was included in the appeal denial

- which stated that investigational or experimental therapies are not covered,

but with two exclusion clauses. The first is if the child is terminal and has

one year to live. The second clause is if the investigational/experimental

therapy shows PROMISE in helping the child's condition. In our case, static

encephalopathy. This is what we argued in the hearing, that HBOT is " promising "

in the treatment of chronic brain injuries.

We lost our case for coverage of HBOT in the future. However, we lost on a

technicality. Aetna had included that " promising " exclusion clause in our

denials in error. In our plan, there are no exclusions, investigational

therapies are not covered. We were told that this was an administrative

cut-and-paste error, that many of their plans have the " promising " exclusion

clause, but ours does not. For those with a policy that has this clause, it is

hard to argue that HBOT does not show promise. Even in Aetna's own clinical

policy bulletin, they state that HBOT is " promising " , and have research about

stem cells forming new neurons, and improvement in mitochondrial function.

Aetna also stated that they feel that much more research needs to be done.

Thanks for all of the advice/support/research along the way. We are very pleased

with the outcome, and for the opportunity to at least present the case for HBOT

to Aetna - even if we won't be receiving future coverage.

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