Heads up -Watchman device not covered by Aetna

Just had a call from Scripps to schedule the Watchman device.
They submitted for prior authorization to Aetna.
Aetna responded with no prior authorization needed. Procedure will be evaluated at time of claim for medical necessity.

Scripps says don't worry it will most likely be covered.

After 3 hours on the phone, Aetna emailed thier policy to me. It states Aetna considers all left atrial appendage closures and devices experimental.

Got to love our medical system.
Make sure insurance will cover before having the procedure!

Here is a link to Aetna's policy http://www.aetna.com/cpb/medical/data/700_799/0791.html?sms_ss=mailto&at_xt=5997414b24e9b84d,0



Edited 1 time(s). Last edit at 08/18/2017 05:34PM by gmperf.

Update on Watchman device procedure insurance approval process.


Today I called Scripps to see if they received the fax I sent last week with Aetna's policy on the Watchman and ALL LAA closure devices and procedures. The second person I spoke with said Dr. Gibson's nurse didn't have time to review the fax yet. She also stated that if Aetna's policy stated the Watchman was considered experimental, they would not appeal the policy or write any letters to try to get approval. They had taken me off the schedule.

I get the impression they didn't care one way or the other if I have the procedure with them.


95% of all my experiences in the past with Scripps had been related to Dr. Natale. I sure miss Linda and Dr. Natale being at Scripps! She and his staff were always on the ball and you felt like they actually cared and didn't view you as just a number or just a revenue generating procedure. I guess that was why I had a high opinion of Scripps. Now, not so much. Perhaps time to move on.

At this time the Watchman device procedure is off.



Edited 1 time(s). Last edit at 08/22/2017 05:55PM by gmperf.

Go to Austin Don,

And give it a little time, the tide is turning quickly toward more insurance coverage for Watchman soon, especially with the very good news from the large 1,065 patient EWOLUTION trial results put out last month from Europe, the Middle East, Russia and Asia. In this trial that including ONLY very sick patients with very high CHADsVASc and high HAS-BLED scores meaning they were ALL at very high risk for ischemic stroke as well as very high risk for hemorrhagic stroke or bleeding events like GI bleeds AND the large majority of these patients could not tolerate a real OAC drug like Warfarin or NOACs and so either had to take only a short course of Aspirin and Plavix, OR only aspirin OR absolutely NO drugs at all that impact stroke or bleeding risk during and after the Watchman procedure were taken by 9% of these 1,065 patients and still the results were very impressive so far or a significantly lower actual stroke and bleeding events over the first year than was predicted by these patients very high stroke and bleeding risk scores.

So this is a group of truly 'dead-enders' who had little to lose and at least time to gain by installing a Watchman to help prevent stroke and lower bleeding risk dramatically,.

It will be a bit of time before this data is published in the US since the US, oddly, does not recognize prescribing Watchman for people who cannot tolerate any OAC drugs when in reality that IS the best target patient group who needs it the most!! Another convoluted rationale that does not ake much sense by the FDA, but there you go!

The bottomline, though, are these very favorable results overall for this first year phase of EWOLUTION trial ... and it will only get better with time ... in, by far, the highest at risk and most severely challenged patients with the highest risk of stroke and bleeding... that shows real world benefit that will only look better in healthier patients with far less cardiac risks profiles to begin with and all the better the farther out we look in time and the greater number of patients followed!

Shannon

Hi Shannon,

The good news is I switched from Eliquis to Pradaxa and I feel pretty much back to normal. I have been on Pradaxa for 5 days now. The brain fog and cotton in my head feeling is gone! I was on half dose Eliquis for the last two months. Even at half dose it was bad. I guess after two years of Eliquis my body said no more.
I am hoping I don't have bad side effects start with Pradaxa or I will be going on Warfarin. What makes the all the more difficult is my local EP still thinks I should not be on anti coagulation. He will work with me but still states it is against his medical opinion.

Dr Gibson's nurse at Scripps still hasn't contacted me. I will assume they just are not interested in working with me. Maybe it is a blessing in disguise.

Yes I may contact Austin and see what they think.

Don



Edited 1 time(s). Last edit at 08/25/2017 10:22AM by gmperf.

Sound good Don, your local EP may be well-meaning, no doubt, but he is woefully misinformed on this particular issue post LAA isolation with a significantly reduced LAA mechanical function.

Go see Dr Natale who did your LAA isolation and I bet you before long things will sort themselves out in your favor, And now that the Pradaxa is working, you have more time and options too but I would keep your big picture focus on LAA closure before too awfully long,

Cheers!
Shannon



Edited 1 time(s). Last edit at 08/25/2017 09:09AM by Shannon.

I finally heard back from Dr Gibson's nurse at Scripps.
She said based on Aetna's policy, insurance would not cover the Watchman device. Took her weeks to read the fax I sent her with Aetna's policy.

Great. Good thing I checked Aetna's policy. I would have had a large bill. They had me scheduled for the procedure and told me not to worry, insurance would probably cover it.
I am embarrassed for thier incompetence.

I asked if they would write Aetna and tell them why I am a good candidate for the procedure?
She said they would not contact Aetna to request they make a decision based on the patient's need because the insurance companies never approve.
I said Aetna is scheduled to update this policy Sept 7th. She said "Yep". I guess "Yep" says it all.

I got spoiled with a top notch, Dr Natale, and his top notch staff. Back to mediocre and worse.

I don't plan on visiting Scripps again unless Dr Natale returns. Cedars Sinai, UCLA, USC, are closer. Or Texas, is worth to travel. I will vote with my dollars.



Edited 1 time(s). Last edit at 09/06/2017 06:42PM by gmperf.

Always go for the brass ring Don ... that is my motto! While no support staff is always perfect, of course, in following so many hear so closely as well
as my own considerable personal experiences there, it really is hard to beat partnering with the maestro at St Davids for their consistently outstanding level care all around!

There are good EPs around the country, but finding one who has such an experienced well-oiled staff as well as the EP him or herself with the unprecedented level of experience and nuance of understanding of this implement field is very hard to replicate.

It's generally far easier and more realistic to add in a travel week to Austin than it is to expect a more convenient option will truly delivery an equal level of care all around ... all
things considered. Especially when addressing more advanced aspects of EP care like LAA/CS isolation/LAA Closure issues.

And yet, it is disappointing to hear the responses you got back from Scripps Green La Jolla after Dr Natale and his excellent NP there, Linda Couts, both moved on from
Scripps La Jolla toward the end of last year when apparently certain procedural changes instituted there ran counter to Dr Natale's standards.

Cheers!
Shannon