Dear Insurance Industry...

A rebuttal letter I recently penned to Aetna regarding a charge they are refusing (so far) to pay after my son's surgery. He's doing fine, by the way.

The surgical assistant’s office that participated in my son’s surgery forwarded me your denial of their original rebuttal and I, as your customer, am outraged. Please consider this as my Level II - and hopefully final - appeal.

This claim for $598.40 was denied because “…the services described…are not eligible for payment…there is no documentation of exceptional difficulty or complications that warrant allowance of an assistant surgeon…”.

Put down your rule book right now. As a human being, I want you to look away from the guidelines that dictate this corporate fiasco and think rationally for a minute. Read this very carefully. On May 5th, 2005, my six month old son had brain surgery.

Let me say that again. On May 5th, 2005, my six month old son had brain surgery.

There is no such thing as brain surgery that is not without “exceptional difficulty or complications”. I don’t care what your code or your Clinical Claim Review Medical Director says. If our neurosurgeon needed an extra hand with my son’s brain, then that is his call. You, Aetna, do not dictate circumstances surrounding the procedure when my son is lying on a table with a hole in his head. That is not your right. If he needed 25 or 30 people in that operating room, then that’s what he needed. Aetna, you stick to insurance please, and leave brain surgery to the neurologist.

In addition to the hilarity of your claims that brain surgery is a solo act, one of your representatives informed me that the reason for the denial was because the service being billed for was for that of an RN rather than an assistant. Well, here’s some news. That person was what’s known as an RN First Assistant/Certified First Assistant. Put simply, in the State of Colorado (where this surgery took place), a Certified First Assistant can indeed provide this service and, in fact, possesses a higher degree of qualification than a generic surgical assistant.
In addition, the code that the Surgical Assistant’s office provided was obtained by using CPT Expert. The acquired CPT code distinctly provides allowance for an assistant for this procedure in accordance with the American Medical Association. Sounds pretty compelling to me.

Finally, I am greatly amused that you even have a tiered appeal process. It is clear to me that you expect the majority of your customers to simply roll over and pay the claim out of pocket when Aetna initially refuses. “We’re not paying this, but if you really want to go through the hassle and spend inordinate amounts of time and energy to fight this, we’ll keep putting you off through a series of fiery hoops through which you must jump in order to avoid any financial setback”. Yep. That’s what it says to me. Seems it would be easier for Aetna to cough up the cash and save us all a little time. Pocket change for you amounts to quite a nice Christmas for my children.

But hey. I’ll play the game. Here’s your Level II in writing. I hope you enjoyed my rant, and I hope you can put a human face on this situation rather than seeing my family’s experience as a code, a case number, or a claim number. My attorneys are waiting for the outcome.

Oh, and one more thing in case you forgot: my six month old son had brain surgery.