Need people as precedence for appeal

[Gin Saw]

Hi,
I'm writing on behalf of a family member diagnosed in Jan 2012 with bicuspid aortic valve regurgitation. He wants a repair surgery and has had two cardiac surgeons say he may qualify for this. But his Kaiser insurance says 'no'. We're writing an appeal. The appeal needs names and info of people who have had this repair surgery. And/or, who have had Kaiser approve them going to Cleveland Clinic for any type of aortic valve surgery.

If you are willling to have your name and info included on this appeal, please email me at



Of click above where it says you can email me.

Thank you!!!

Gin Saw

 

[AgilityDog]

Does Kaiser not want to do the surgery at all, or do they only want to do a replacement?
I have not heard of many aortic valve REPAIRS.

 

[Lynlw]

Hi,
I'm writing on behalf of a family member diagnosed in Jan 2010 with bicuspid aortic valve regurgitation. He wants a repair surgery and has had two cardiac surgeons say he may qualify for this. But his Kaiser insurance says 'no'. We're writing an appeal. The appeal needs names and info of people who have had this repair surgery. And/or, who have had Kaiser approve them going to Cleveland Clinic for any type of aortic valve surgery.

If you are willling to have your name and info included on this appeal, please email me at



Of click above where it says you can email me.

Thank you!!!

Gin Saw

I had the same questions at AD, but also wanted to suggest yo remove yor email address and ask people to PM you, or email thru here, since this is a very public forum and youll probably get lots of spam

 

[Bill B]

I don't understand the issue you are having. The surgeons say he MAY qualify for repair (as opposed to replacement). I emphasized the word MAY. That means they aren't sure. Some mild valve problems can be repaired. Some can't. Also, the repair is often just a stop-gap measure for BAV which generally deteriorates over time. I don't know who at Kaiser is "denying" your claim, but they MAY be right. Anyway, if your relative strongly prefers repair, you need a surgeon with Kaiser to go to bat for him. Any of us here who do not know anything about his case and would not have the slightest authority or professional training to say Kaiser is wrong to deny you, would not have any standing in your appeal and just wouldn't do you any good at all. And besides, nearly all of us here with BAV have had replacement or face that sometime in the future.

Then you mention the Cleveland Clinic. You don't have PPO insurance. You have Kaiser. Almost anyone can buy PPO insurance, which may give them the luxury to go just about anywhere, for a price. That's why I was able to go directly to Stanford without any referral or approval at all, as long as they were a member of my plan. I don't believe I would have been able to run off to the Cleveland Clinic, but I did have the fredom to go to what I thought was the best place for me in California. Had I accepted Kaiser insurance, offered at a huge discount over PPO by my wife's employer, I would not have had that choice unless Kaiser thought they could not handle my surgery. That does happen sometimes. Kaiser will refer cases out, certainly if the Kaiser facilities in your region do not offer the service needed.

So, my recommendation is to see if one of the Kaiser surgeons will appeal. If they have already and are not willing to go further up the ladder, you need to rethink this.

 

[Gin Saw]

Hi,
Kaiser wants to do openheart replacement. But cleveland clinic is doing repairs. Kaiser in Ohio uses the cleveland cllinic for its surgeries. I don't know how many are repairs vs replacement.

 

[Gin Saw]

Hi Lyn,
Good idea to remove my email address in the body -- I did that. Thank you. Can you now remove it from your reply?
Ginger

 

[Gin Saw]

Hi Bill B.
Very clear and helpful. I appreciate that. I guess it's my family member's call. He wants to have a repair at Cleveland Clinic. He knows that replacement may be his final option, but he wants the chance. When he selected Kaiser, he did not know about the valve misfunction and he is not eligible for a ppo at this time. When the time is right, he'll make the decision he needs, I'm sure. Meantime, there is historical evidence that having precedences in an appeal can make a difference. When the health insurance companies have received these appeals with precedences, the companies changed their decision in almost 100% of the appeals. So, my brother is hopeful he'll get some people to contact him.
Gin Saw

 

[yotphix]

Does Kaiser not want to do the surgery at all, or do they only want to do a replacement?
I have not heard of many aortic valve REPAIRS.

Perhaps not, but they are done. When my surgeon got in, and got a look at my valve, he thought briefly that he might be able to do a repair instead. In the end he judged that the replacement was the better option, in part because we were aiming for no more surgeries (hence my mechanical choice.) Regardless, though it was not appropriate in my case, it is done.

 

[dtread]

Gin, your quote: "Kaiser wants to do openheart replacement". Presume you mean aortic valve replacement. Also, sounds like Kaiser is open to allowing the surgery, but as a replacement, not as a repair. Kaiser has contracts with various hospitals and medical centers for advanced procedures like AVR. Cleveland Clinic may not be one of the facilities that Kaiser has a contract with. Also, it is not local to where your banner indicates you are from (Denver), although you do not indicate where your relative that is having the problem is from (Ohio?). If your relative is so dead set on Cleveland Clinic I'd recommend that he/she set up an appointment with Cardiovascular Surgeon at Cleveland Clinic and get an opinion from them. Dig into wallet.

 

[Gin Saw]

Hdthread,
Yes, aortic valve repair is my family member's 1st choice. Kaiser Ohio and Cleveland clinic are connected, so he could conceivably go thru Kaiser Ohio to have access with Cleveland clinic. And, yes, he is considering paying for it himself. But he was hoping he could talk his local Kaiser into referring him. Thanks for you feedback. Gin Saw

 

[Gin Saw]

Lynlw,
Thanks for removing the email address!
Gin Saw

 

[Luana]

Hi,
I'm writing on behalf of a family member diagnosed in Jan 2012 with bicuspid aortic valve regurgitation. He wants a repair surgery and has had two cardiac surgeons say he may qualify for this. But his Kaiser insurance says 'no'. We're writing an appeal. The appeal needs names and info of people who have had this repair surgery. And/or, who have had Kaiser approve them going to Cleveland Clinic for any type of aortic valve surgery.

I'm an insurance agent and fairly familiar with Kaiser Permanente. I can't imagine them, or any insurance company for that matter, wanting information and experience of patients, and not medical doctors to approve a surgery; it's unheard of. Anyone can say anything; anecdotal experiences are meaningless, totally meaningless, to an ins company.

Do you really think KP will base their decision on the experience of patients over what a doctor says? I'm wondering if something about what's needed for an appeal is misunderstood. I wonder if they want that info from surgeons who will give patient info and records. Something here is not right.

From what I know, when a KP doc deems a surgery necessary, it's approved. It sounds like he wants to go out-of-network to Cleveland Clinic; that's the problem.

Also, Laurie is correct. Aortic valve repairs are not common; if he indeed has severe regurgitation, the valve is probably beyond repair and needs replacement. As for the two docs that say he "may qualify" for repair, that's a bit vague. Either he's not had advanced testing, such as a cardiac cath or CT scan, and they're not sure if the valve can be repaired, or they truly do not know until they open him up. Again, there's a lot here that just doesn't sound right.

KP can do a valve replacement just as well as CC. If you want to appeal this, you'd do best to get the assistance of someone familiar in doing such things and has all the ducks in a row to present an appeal. Appeals are constructed on facts, not anecdotal evidence.

 

[Bill B]

OK, so your relative is in Ohio and Kaiser there has a relationship with the Cleveland Clinic. That's great. I'm surprised the Kaiser cardiac surgeon does not offer valve repair if indicated, so you seem to think referal to the Clevelansd Clinic is the answer. Something doesn't add up here.

One thing the Clinic does a lot of that may be beyond some other cardiac surgery centers is minimally invasive surgery. If that's what your relative wants, yes, the Clinic may be the choice over Kaiser.

 

[Gin Saw]

Luana,
I found you comment very helpful. Thanks. the thinking on the precedents: If Kaiser has done something similar for someone else, then it would give strength to the request to do it again. The two cardiac surgeons only had my family member's medical records to review. Both said it looked ok for repair, but as you said that may change once inside where the valve is visible.

 

[Gin Saw]

Bill B,
My relative is not in Ohio -- which is the problem. Had he been, then the Kaiser Ohio would have sent him to Cleveland clinic. CC would have decided what and how to do the surgery. My relative does want minimally invasive as well as repair of his aortic valve. I hope this has clarified what I wrote before.

 

[Bill B]

OK, if he wants minimally invasive surgery, which I concluded could be a problem for me, then he does need to go to a center, like the Cleveland Clinic, which does a LOT of this. I'm not sold on minimally invasive. Yes, there is faster healing and shorter hospitalization - big pluses if significant. However, it can be as or more painful than sternotomy (note I had ZERO pain with my 11" sternotomy incision) and it does not provide enough room for certain procedures (like my arch repair) to be done with results as good as sternotomy. So, to me it's toss-up and I can see why Kaiser is saying, sorry, no dice. The result will be essentially the same with sternotomy or minimally invasive surgery. Now, I think Kaiser would be smarter to encourage minimally invasibve surgery among its own surgeons if hospital stay is notably shorter - that would save Kaiser money. I worked at Kaiser when I was in school and it surprised me how they often don't follow practices that would save them money.

 

[Gin Saw]

Hi Bill B.
I quite concur that Kaiser should be saving money with the minimally invasive procedures. Some Kiaser regions do use this procedure for aortic valve. But the region my brother is in, does not. Your surgery sounds like the textbook case and is a good role model for others to read about. Congrats!

gin saw