Quick question - has anybody had surgery approved using either Banner or Aetna insurance? I have met with Dr. Nakaji in AZ, but my Banner-Aetna insurance has denied me twice saying the surgery is experimental and not medically necessary. I have one more appeal left, and I’m hoping that if I can show they approved it for someone else, they should do the same for me. I’ve had all the preliminary tests done and approved/covered showing I have this condition, including a cerebral angio/veno with Dr. Mehta in AZ. Thanks!
Your insurance company should have a patient advocate on staff & if they don’t, you can probably find one online. That person should be very helpful for you. Sorry I don’t know of anyone who has used Banner or Aetna w/ Dr. Nakaji so can’t help you there.
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Thanks. I’ll look into that as another option.
@tguerin18 It matter what diagnostic code they use and the treatment procedure codes. There is no diagnostic code for Eagle’s or VES. Dr. Nakaji used G93.2 which is pseudo tumor cerebra syndrome, benign intracranial hypertension and M89.8X*, Elongated styloid process syndrome, other specified disorders of bone.The procedure codes were as follows 38724, 61605, 61590, 61781 and 69990. I don’t know what they all represent but my insurance company (eventually) paid the claims.
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Did you happen to have Aetna or Banner insurance for this?
No, I have Blue Shield of CA and had my own struggles getting them to pay but that was because Dr. Nakaji is out of state. I got the state’s Board of Insurance involved and wouldn’t have been successful without their help. Good luck to you!
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It’s a different company, so I don’t know if this is helpful for you, but there might be some useful info:
Dr Osborne- Blue Cross Blue Shield Out of Network Waiver-2025 - Welcome / New User Help - Living with Eagle
And there’s links to another couple of other discussions about fighting insurance companies…
Good luck!
It’s a different company, so I don’t know if this is helpful for you, but there might be some useful info:
Dr Osborne- Blue Cross Blue Shield Out of Network Waiver-2025 - Welcome / New User Help - Living with Eagle
And there’s links to another couple of other discussions about fighting insurance companies…
Good luck!
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So glad you were able to get it approved through the CA Board. That will be my last chance if my 2nd round appeal doesn’t get approved. AZ has an external review with an independent doctor at the end if all else fails. The insurance company has to abide by the decision. Don’t really want to get to that stage, as this is taking a while, but I’m guessing my 2nd round appeal will get declined too. The insurance company is being difficult. Shocker! 
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Thanks, Jules! Really appreciate this.
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One other general question for the group, too. Why would my insurance approve and pay for me to have a cerebral angiogram test with Dr. Mehta, which as a lot of us know is an invasive test/surgery, and then deny me for surgery with Dr. Nakaji. This is the fix for the test they approved in the first place. Makes no sense.
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I don’t have an answer for you, @tguerin18, but completely agree it makes no sense. Have you used that as an argument in your favor in your appeal?
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I’m not sure what has been used to be honest. Dr. Nakaji’s office uses an outside company to help get this approved. I had some contact with them at the beginning, but not sure where things stand what all has been submitted. I do know they got another letter from a neurosurgeon in Phoenix talking about this condition and why Dr. Nakaji should do my surgery, but the insurance didn’t budge. I’m going to hopefully talk with them this week to see what else we can submit to strengthen our 2nd appeal.
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What you are going through is so frustrating and I hope you are holding up okay. It’s challenging to put up ’the good fight’ while feeling so ill. Let me know if I can support you in the process.
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Thank you! I really appreciate that! I considered myself to be fairly tough with a decent pain tolerance. I was a high-level college athlete in swimming and have remained active my whole life. However, this has been really challenging over the last 3 years. I’m to the point now where I need help from the medical professionals. It’s very humbling. Hopefully I can get it. Thanks again!
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