Ablation Surgery Denied by Insurance Company

Can an insurance company like Aetna, to whom you pay thousands of dollars each year, deny you the medical treatment or surgery that your doctor prescribes to alleviate or cure your condition? Unfortunately, the answer is sometimes yes.

A common condition that can sometimes be cured or alleviated by a very expensive surgery is epileptic seizures. It is often impossible to predict when seizures will hit, and that fact makes them terrifying—the patient has no conscious control over them or any idea of what their effect will be. They can be triggered by just about anything: stress, emotions, physical activity, or just normal aspects of everyday life.

According to one Aetna patient, her body gets cold and then shakes, zoning out for anywhere from a few seconds to several minutes. During episodes, she is aware of her surroundings, but cannot snap out of it; she compares it to being awake during a nightmare. It affects her entire life every day.

There is a minimally invasive surgery called ablation surgery that can be used to treat seizures. In this procedure, a thin laser goes through a small hole in the patient’s skull and heats and destroys the lesions in the part of the brain where the seizure begins.

Neurologists consider it to be much safer and more precise than regular brain surgery, which requires the top of the skull to be removed and is much more dangerous. Traditional brain surgery can cause serious complications, including death, and recovery time is six to twelve weeks. Comparatively, recovery time from laser ablation is about two weeks and usually involves much less pain and fewer complications.

However, Aetna—the third-largest health insurance company in the US, covering over 23 million people—denied coverage for this surgery, even though the patient’s doctors said it would be effective in stopping the episodes. Instead, they approved the open brain surgery, called a temporal lobectomy. Her medical team never asked for approval for this procedure and did not recommend this surgery to their patient.

Aetna’s reasoning was that laser ablation surgery, which would cost a patient $300,000 without insurance, was experimental and its effectiveness was not established.

However, the instrument used for the surgery is approved by the U.S. Food and Drug Administration, and the surgery is considered to be effective—and not at all experimental—among neurologists who spend their lives treating people with epilepsy. It would be especially effective in the case Aetna is contesting, where the specific location of seizure activity in the brain can be pinpointed with such accuracy.

This scenario could happen to you. If you are denied medical treatment by Aetna or any other insurance company, it can be a life or death situation. A skilled insurance denial attorney could guide you through this confusing time and begin the administrative paperwork to appeal the decision. They could research your case, interview experts, and manage the legal process to get you the medical care you deserve.