[o2bponca]

Does anybody have Aetna HMO? I was so thankful my local (in my network) vascular surgeon opted to NOT do my surgery (or even decide if I should have it) because of a lack of experience. So, he sent me to someone with more TOS knowledge and surgeries under his belt. The dr. he referred me to is Dr. Jeff? Ballard in Orange, CA. He's on Aetna's HMO plan, but not in my physician's group. Naturally, I had to get authorization through a request from my PCP just to consult with this "new" surgeon.

Apparently, my medical group physicians actually decide if the auth. will be approved and they chose to deny mine saying that I need to see someone in my group. But, what if there's NOBODY with TOS experience in my group? I don't want some Joe-Smoe doing it! Don't they understand it's a relatively rare condition that many physicians don't even know about? What if some doc with a big head on his shoulders decides he's good enough to do it, even without experience? Don't I have a say in who does it - somehow?

I guess I don't really understand how the whole HMO thing works in this situation (haven't had to deal with it yet). If anybody can help, please write!

UGH - I'm so frustrated, I want to scream! Thanks for listening.

Carrie

[(Broken Wings)]

yeah, you're not the only one who wants to scream, and with good reason. I have had experience with out-of-pocket services. You can have it, but you will also end up paying for about 80% of the total bill yourself. You can write a letter of medical necessity and sometimes, because of his expertise and if they're not another comparable surgeon for your condition (if the 1st doctors writes a letter stating he's not qualified for your situation, and he's within your group, they may allow it under your HMO. Don't hold your breath though. They really don't have to. I fought the system and I paid is all I'll say. Maybe there's another doctor within your HMO. A longshot, but try to talk the surgeon's office into joining your HMO. It's a contract between the provider and insurance co. Aetna is good to pay, just by their rules. You probably have a policy there that will explain a lot more than I can about your ins. I ended up contacting my state representative and the Department of Insurance. I made a lot of noise, but in the end I still paid.

It's not fair how insurance companies, or the lack of coverage, can make you suffer too.

[astern]

Hi! I had Aetna for my 4 surgeries.

The first surgery was in-state but not in my city. The Dr. was in the Aetna HMO Network. This guy knew nothing of TOS and did me serious damage. Lucky for me he didn't attempt the rib resection, but he mangled a nerve in my rt arm and caused some scar tissue.

After this botched surgery, a Forum member (Beloved Beth) directed me to one of the top TOS surgeons in Denver. He sent a letter to Aetna - and I spoke directly to Aetna, explaining the need to go out of state. I do believe "Dr. A" accepted Aetna Insurance. I was cleared for the next 3 surgeries! Aetna realized the 'expense' of sending someone to a surgeon who is clueless.

My last surgery (bi-lat pec minor disinsertion) fell at the end of my coverage - literally 4 weeks from cancellation. For costs associated with the hospital that I had to pay out of pocket, I was able to write a letter to the Hospital board requesting assistance as I was unable to work now. That last procedure ended up costing me $13. I did agree to pay my surgeon his requested amount (which he discounted for me), so that was more.

I hope my dealings with Aetna haven't made it harder for you. They now know what is involved - the PT required, the risks involved and the need for surgical assistants (which requires advanced approval from Aetna).

If your surgeon is not in the Aetna Group, his office staff could get him signed up - if you ask. PM me if you need any of my reports to jogg Aetnas' memory. maybe you'd have better luck seeing my surgeon?

good luck!
Anne

[astern]

Family Guy on HMO's.

Oh, I forgot to mention that after my first consultation in Denver, the Dr who did the failed/attempted surgery got dropped from Aetna? I got a copy of that letter.

[o2bponca]

Thanks for your input - I really appreciate it. My PCP referral gal is working on this still, but says my next stop has to be Loma Linda Univ Med Center. While that's a VERY reputable hospital, I'm still not sure if there's a TOS-worthy doc there.

I have a feeling that, if I do require surgery, I'll need more than one 'cuz the symptoms on the right are getting pretty significant too now (started on left). Also, my left arm is losing blood flow at lower and lower positions - even holding my arm (lightly) against my chest, elbow down, with my hand on my face to put on lipstick or whatever. And the veins in that arm are starting to actually bulge a little. The nerve pain is "lovely" too (not!), as I'm sure you know.

Naturally, I'm getting anxious for this process to move along! I don't want to end up in some emergency situation with PE/blood clot/stroke or something and at the mercy of a doc in my closest ER.

I hope they figure it out - just waiting to hear - and waiting - and waiting. I wonder how many docs I'll have to consult with (at the insurance's expense) before they'll agree to send me to the RIGHT one!

[astern]

Just in case this is helpful: the Dr. that Aetna sent me to (who did the first failed surgery) was a TOP thoracic surgeon. Heart/lung transplant guy. Very experienced...

... but no experience with TOS or cervical ribs.

Honest, if you want me to give you the info for Aetna, just PM me.

Anyone in CA have a line on a TOS Dr. for o2b?

[o2bponca]

Time for an update --- and here I still sit . . . waiting . . .

At Loma Linda UMC, entire board of vascular surgeons got together and went over my case; decided that no one there could handle the case and that I needed to see Dr. Ballard (gee, that name sounds familiar, huh?) - was already referred to him once and later denied by insurance.

Insurance decides "no" AGAIN to try to stay in-network and sends me to a great vascular surgeon at UCI. I even call before I go so as not to waste my gas getting there only to find out he too knows nothing about TOS. His nurse says, "Oh yeah, he handles TOS cases all the time." So I drive for 2 hours to get there, do his complete eval (including students and residents before seeing the real doctor). Dr. pretty much blows off my symptoms because my arm's not falling off yet and tells me he only does surgery for obvious cases with blood clots forming in the arm/fingers and immediate circulatory compromise. To my surprise, he mentions a different surgeon (but still one I've heard of), Dr. Gelabert at UCLA. That's a relief as I already know he really DOES handle a lot of TOS cases - and well, too! Oh, yeah, but there's a problem - AETNA!

UCI Dr. promises to help out with insurance by talking to them on the phone, writing letters, or whatever he needs to do to get me to UCLA for an evaluation (and testing 'cause he's not even convinced I have TOS, despite all the neurogenic symptoms, loss of pulse at MANY positions, bulging venous collaterals getting bigger every day (and now appearing on the right too), disappearing venous collaterals (and pulse loss, of course) with abducted arm (suddenly reappearing when arm is put down).) All I can think of as I'm driving the 2 HOURS home from UCI is about handling the next 6 months while I battle the insurance company again. All I can say is, if I end up losing a limb or "throwing" a blood clot, they WILL take care of my kids!

So, that was - what? - 3 or 4 weeks ago. After giving up on bothering my PCP referral gal (who has been saintly and put up with me since last April already), I've resigned to sitting and waiting for them to get their *!#(* together, figuring out ways to deal with the pain and the lack of circulation, and pray that the blood keeps flowing!

To top everything off, I can feel my pulse in a spot above my collarbone now - don't think that's normal! UCI Dr. said there's no hurry because he didn't see a subclavian aneurysm on my angio (that was done in October!!!). By the way, I've never had an ultrasound.

Yesterday morning I woke up and could count my pulse just by looking at the clock because I could feel it in my head - without using my hands! On several other occasions, I've been able to do the same but by the pulse in my swollen hand(s). Hey, I guess I could look on the bright side - most people (except here, of course) don't have that talent, right?

It's so much easier to assume (or pretend, or whatever) that it's not fixable or operable and that I just have to learn to live with it - and forget about getting a real doctor to tell me so! I guess I better seriously look at some better methods of pain relief than the temporary medications I've been using just to "get me through".

Thanks for listening - you guys are awesome!

[Jomar]

EEESH, all that delaying is almost as bad as a work comp case...

You'd think pvt medical would be a little bit more cooperative.
If a few drs write that you do need to be seen by some specific drs , the Ins might finally OK it.

Pulse "whooshing" in your head - I had that for a long time.
Finally went away when we {me, chrio & adv PT } got rid of the scalene & SCM spasms and got the top ribs to drop down.
It still comes back if i do too much and don't take the down time to R & R it.

I didn't have much for neuro sx or pain, just some minor stuff & my fine finger coordination affected.

I hope you don't have to wait too long ...

Have any Rx'd any specialized PT or bodywork for you - or did it not work out well for you?

[o2bponca]

Although they've all talked about it as an option, none of the doctors have specifically prescribed PT or chiro. Actually, they've told me to stay away from chiro altogether. They want me to try PT, but don't know enough about TOS to know what kind, good PT's to recommend, etc. Everyone seems to be holding out to get me the right doctor who knows what he's dealing with.

Meanwhile . . . it's been 10 months since S/S started.

Called PCP today, they said they haven't received any paperwork from UCI yet so that they can START processing the referral (from a visit flippin' 4 weeks ago!) . Ugh! That makes me so cranky!

Called UCI to find out what their problem is. All they could tell me so far is that Dr. has been on vacation since 2/12 and won't be back until the 22nd. Have a call into his nurse - waiting for return phone call.

[tshadow]

Originally Posted by o2bponca

Does anybody have Aetna HMO? I was so thankful my local (in my network) vascular surgeon opted to NOT do my surgery (or even decide if I should have it) because of a lack of experience. So, he sent me to someone with more TOS knowledge and surgeries under his belt. The dr. he referred me to is Dr. Jeff? Ballard in Orange, CA. He's on Aetna's HMO plan, but not in my physician's group. Naturally, I had to get authorization through a request from my PCP just to consult with this "new" surgeon.

Apparently, my medical group physicians actually decide if the auth. will be approved and they chose to deny mine saying that I need to see someone in my group. But, what if there's NOBODY with TOS experience in my group? I don't want some Joe-Smoe doing it! Don't they understand it's a relatively rare condition that many physicians don't even know about? What if some doc with a big head on his shoulders decides he's good enough to do it, even without experience? Don't I have a say in who does it - somehow?

I guess I don't really understand how the whole HMO thing works in this situation (haven't had to deal with it yet). If anybody can help, please write!

UGH - I'm so frustrated, I want to scream! Thanks for listening.

Carrie

Print out our docs list and show it to the doctor or fax it with a letter to the insurance co. saying, I have a rare condition and there are only certain surgeons with enough experience to do a brachial plexus release with scalenectomy (or whatever you think your surgery would be, if diff.), and for Dr. Annest they had the curricular vitae (spelling?) basically listing ALL of his experience and publishing in the TOS field.

Whenever dealing with Ins. Co.s, if you send a letter certified, this seems to lay a paper trail for a malpractice / bad faith claim, and they then do the right thing.

I don't know Dr. Ballard, and I lived in OC all of my life until just recently.

Hoag Hospital has a GREAT TOS PT, they don't push you, in fact, they know that ANY pain means, stop, with neuro TOS. Their knowledge was great.

I see you're in Temecula. Tell them to send you to Dr. Jordan - for our OC group, I think he was tops, for identifying what you have (diagnosis) and treatment options.

Unfortunately, we have to go many miles to find a knowledgeable doc and one who can write well. For surgeons, I suggest Denver. For the top docs there, they DO take insurance, and I know Dr. Annest's office works hard to get authorization.