Pacemaker Denied - 3rd Degree AV Block

You must be feeling awful!

by shirley d - 2019-02-26 07:09:17

So sorry that you are going through this. I am sure your Dr is going to sort this out,

Do you have some sort of council you can appeal to, They have to give you reasons!... Perhaps ask for them in writing,

Let us know and good luck!

Yikes!

by AgentX86 - 2019-02-26 08:41:43

What does your EP say about this? This has got to be a screwups somewhere along the line.  Perhaps your EP's office coded it wrong. Perhaps they've coded it as a type one? What was the diagnosis?

It shouldn't have taken this long for the insurance company to respond. There is something else going on. You need to talk to your EP, now.

Update

by BHVietak - 2019-02-26 10:19:00

My EP has been working with them and is trying to get this squared away.  She got so frustrated when we found out yesterday afternoon that she called and demanded a peer-to-peer today.  Unfortunately I do know this wasn’t a coding issue as I have spoken to both Aetna and EviCore (their pre-auth processor) myself.

I’ve been calling around to family members who are doctors and one who works in insurance.  They all are disappointed in Aetna but no one is surprised since apparently Aetna has clerks review claims first and a doc reviews upon appeal?  Although the doc reviewing isn’t guaranteed to be a cardiologist, much less an EP, but even my uncle who is an ophthalmologist didn’t understand how this ended up denied... so I have hope.  Thankfully they think this will get rectified even if I have to get the surgery and report them to the regulators after the fact to help force reimbursement.

Yikes! (again)

by AgentX86 - 2019-02-26 10:35:47

Aetna does have a poor street cred but I have to say that they've been great for me, even going after hospitals to pull a fast one on me. Like any big company, it's run by bureaucrats sl anything can happen. Your EP has to stick with it. Clearly this isn't experimental surgery and a complete heart block is serious. Since you have conduction at times, they must think it's type-1.

It can't be any fun being in your position but keep hammering them until you find someone with a brain

Emergency

by zawodniak2 - 2019-02-26 10:49:30

Try faking that you  passed out and call 911 and  go to an emergency room. Maybe that will get their attention??🚑🙏

             Rodger 

zawodniak2 - Yes !!

by MartyP - 2019-02-26 11:14:45

If you pass out and someone calls 911 and you get to an emergency room in the hospital you want to go to, not only will you be safe there, but the chance of getting your needed pacemaker on an emergency basis will be far more likely especially if its the same hospital that has admitting privileges for your cardiologist / EP ..  If that's what happens have the person with you that calls 911 also call your cardiologist / EP as soon as the ambulance has you and you are on your way to the hospital.     Please keep us informed.  That was my story - out like a light, ambulance to emergency, PM next morning.

Similar Situation

by Newbie4444 - 2019-02-26 17:20:49

I am 37 and wore a holter last month and they found about 5 episodes of 3rd degree heart block in me also. Due to my vagal nerve. I also have AETNA. I have pacemaker surgery scheduled for March 8. How do you know they will deny your claim if you haven't had the surgery yet? I called AETNA a few weeks ago and asked the woman if they cover pacemaker surgery and she told me yes. Is it even possible to submit a claim before the procedure is done? 

Denied again

by BHVietak - 2019-02-26 19:21:52

I got some bad news, it was denied again after today’s peer to peer review.  We don’t understand why.  EviCore and Aetna are still denying on the grounds that it is not medically necessary.  It looks like I will end up in the ER next time I have a problem.

To the person with Aetna... please make sure your doctor stays on top of any prior authorization requirements.  This has been a nightmare with my policy.

Welp, that was fast

by BHVietak - 2019-02-27 00:37:56

Well, that was fast.  Pulse dropped to the 30s three times this evening and I almost passed out so I’m in the ER.

Wish me luck.

Universal health care

by AgentX86 - 2019-02-27 09:01:04

Perhaps not but they have other problems I'd rather not have. But this is a discussion for a political forum.

Swangirl, "none of this ever happens"

by Tracey_E - 2019-02-27 09:39:08

Oh yes it does, and often . We have a lot of members, including our site owner, who are Canadian and it can take them months and months to even get an appointment much less a diagnosis and surgery approved and scheduled. I have a friend who was diagnosed with cancer. It took her a year to get enough tests to get a disgnosis. That was in November. She was scheduled for surgery in April, but they kindly put her on the waiting list in case something opened up sooner. Don't assume the grass is greener on the other side, it's just different grass not necessarily better grass. 

I'm just going to throw this out there. NOT saying she doesn't need a pacer because I'm not a doctor and don't know her full history, but incidents of complete heart block are by definition 2nd degree block, not 3rd degree, which means pacing isn't always necessary. Complete/3rd degree means we stay in block all the time, 2nd degree means either partial block all the time or going in and out of full block. An insurance company is going to treat 2nd degree differently than 3rd degree so my guess is this is where the problem is. 2nd degree can still need pacing, but it's a harder sell than 3rd degree when the insurance company is being a tightwad. 

...

by BHVietak - 2019-02-27 11:42:01

I’m not an expert in the nuances of these things, but my understanding was that complete heart block is third degree.  I did a quick google and it seems like the internet may agree: https://ekg.academy/learn-ekg?courseid=316&seq=7

Is there maybe another one which you’re thinking about?  I thought perhaps that’s the problem but it was definitely described to me by my cardio as third degree with a pacemaker required and no other real treatment options.  I was really anti-pacemaker at first and it took a bit of thought for me to get over the hump that I actually needed one.

Complete 3rd degree

by Newbie4444 - 2019-02-27 11:51:36

BHVietak- you are correct. Tracey_E is incorrect on her definition of complete/3rd degree HB. I was diagnosed with complete 3rd degree HB by University of Penn Electrophysiologists. Any episode of 3rd degree HB requires a pacemaker. The only time it 'may' not require a pacemaker is if it was vagally induced. If anyone stays in complete 3rd degree heart block all the time, they would be deceased. 

As far as universal healthcare goes- appreciate what we have here in the USA, people! But yes, please keep these political discussions off of this site- they could give someone a heart attack :)

types of block

by Tracey_E - 2019-02-27 14:31:33

Newbie4444, I lived for 27 years in complete block all the time as have many others. The heart has an emergency back up system so it still beats, it just does not beat in sync with the atria and it's usually too slow. It's called junctional rhythm where the ventricles contract at random. I've lived my entire life with this, pretty sure I've got the definition down.

BHVietak, whatever the label placed on it, being in complete block all the time is not the same diagnosis as being in complete block intermittently. One requires pacing, the other may or may not so the insurance company may question it. It sounds like you do need it and the insurance company is being jerks.  I was just taking a guess at why they were being jerks, not trying to split hairs or start an argument. :o) 

If your doctor isn't getting anywhere going through channels, ask him/her about the effectiveness of going to the ER every time your rate dips so there is lots of documentation of your symptoms, perhaps even admitting you. Sometimes the rules change when you are admitted and things can be approved more quickly because it's labeled an emergency. 

To answer your question, complete heart block is another name for 3rd degree heart block.  You go in and out of block which is better than being in block all the time because sometimes, probably even most of the time, your heart beats normally. This is a good explanation of the types of block. 

https://www.nhlbi.nih.gov/health-topics/heart-block

Here's another good explanation from the Heart Rhythm Society. Periods of 3rd degree block fits into 2nd degree type II according to this definition

https://www.hrsonline.org/Patient-Resources/Heart-Diseases-Disorders/Heart-Block

Good luck getting it resolved quickly. If you have questions about the surgery or recovery, don't be shy. Most of us find the surgery easier than expected and quickly get to the point we rarely think about it. The pacer fixes what's wrong and we can get on with our lives. 

Update: I have a PM!

by BHVietak - 2019-03-07 18:31:23

So it’s been a long week and a half but I have an update.  I finally got my PM.  Ironically, Aetna called while I was getting it done to tell me that they would be paying for the surgery.

Surgery was a few hours ago and it’s amazing how much better I feel already.  I called my boss and filled him in and he said he could hear from my voice how much better I sounded.

Thank you so much for all of the info people shared here and I’ll be sure to let you know if I have any questions as I get used to my new best friend.

great news!

by Tracey_E - 2019-03-17 09:08:42

Glad to hear Aetna came around, you got your pacer, and most of all, you are feeling better! How are you doing now?