Aetna Gamma Knife Coverage Help

[Tigoer]

Dear all,

I am a new member and I am 1 1/2 weeks away from Gamma-Knife radiosurgery for a right-sided 17x18 mm acoustic neuroma. I have chosen the Pittsburgh group at UPMC mainly based on their published 10 year follow-up results from last year (for anybody interested: Chopra R et al. Long-term follow up of acoustic schwannoma radiosurgery with amrginal tumor doses of 12 to 13 Gy. Int J Radiation Oncology Biol Phys 2007;68(3)845-51.). I will send articles pdf the file gladly to anybody who would like to read it.

My problem is that the University of Pittsburgh Medical Center (UPMC) is not in the Aetna network. UPMC has estimated treatment costs at around $40,000.  Although my insurance allows out-of-network service, it will pay a percentage of my treatment costs only related to what Aetna considers "usual and customary". The quote I have gotten from Aetna for the coverage of the entire procedure is so low that I am a bit baffled. For procedure 61793 (the procedure code for stereotactic radiosurgery - which covers procedures such as GK, CK and the proton beam treatment) Aetna proposes to pay at max $7,030.

Can any of you who underwent Gamma Knife or any other form of radiosurgery (Cyberknife, LINAC or proton beam radiosurgery) and who had previous experience with Aetna share with me what the covered amount for your treatment was? I would greatly appreciate the information as a reference.
Similarly, even if you were covered under other plans the amount your ended up being charged by your treatment center would help me to get a better understanding what are the "usual and customary" cost for the procedure around the country.

Thanks in advance,


Uwe

[Dan]

Hello Uwe,
 
I'm sorry you had to join us, but glad you found the site.  I can't help you very much with insurance, or costs in the USA but I know here in germany GK Frankfurt told me the cost would be Euro 9,000 (around $14,000) and that most insurance companies here wouldn't pay for the treatment.  I can hardly believe that in the USA the costs of GK is 3X as expensive as here.

Good luck in your search for info, you have found the right place to look for help.

Dan in Germany

[sgerrard]

I'm afraid that in the US, anyway, UPMC's number is probably low - I think many times it is over $50,000 - for me, Cyberknife certainly was.

One question on  the Aetna quote: you listed it as a specific procedure number 61793. I saw the billing on my CK treatment, and it was broken down into many individually billed items: MRI, CAT scan, treatment planning, procedure each day, doctors each day, consultations, hospital fees, etc. Maybe that figure is for just one of the codes they use?

I would suggest you get someone at Aetna and someone at UPMC to speak to each other by phone, especially if you can also provide both ends with the radiologist report from the MRI, and a hearing test. Maybe if Aetna hears the actual list of codes involved, they can give you a better idea. $7,000 can't be "usual and customary" for any complete radiosurgery treatment, especially one involving neurosurgeons and the human brain.

I Hope you get some better support from Aetna.

Steve

[OMG16]

Just an FYI the usual and customary is not determined by what others charge for that procedure code exactly.  They lump in different costs for that procedure code and then your employer buys a certain plan that can range from a 25% usual and customary to 100% usual and customary.  You will not be told this by your employer or the insurance company.  There is a national ucr percentage document for different procedures however only the insurances have access to it.  Also when you are out of network they have been known to lower the usual and customary amounts.  Since UPMC is not contracted most of the expense would be yours.  There are laws that state if you do not have a qualified Dr within a 30 mile radius from your home then they must cover as if the facility and Dr are in network with no additional cost to you other than your co pay or 20% for example.  You may want to try to get an exception for coverage.  It is tough work but is worth a try.  Just always remember that no matter what their documents of pre authorization will always say that they have the option after the fact to deny the claim.  Always get everything in writing and keep very good record of who you talked to and when.  If you need some help with this send me a pm and we can give it a shot. 

My son went out of network and I was able to get them to pay the surgeon 100% billed charges.  I have fought regence, blue shield and the VA for friends and family and won all appeals.  I do this for a living now due to my experience and have Drs offices calling 2 or 3 times a year for consultations to set up their billing dept.  Unfortunately there is not enough time to do this and must just focus on my son and the boss I have now as she is very good to me.  I can certainly help an fellow AN forum member to the best of my ability.  Just let me know.  Good luck and I hope that your treatments are a success. 16