Insurance denied my appeal

Insurance denied my appeal for my Dr. Natale ablation. Talk about kicking people when their down.

Went to my local EP to have him start filling out chart notes from here on out as if the sky is falling. Told him I was planning on having Dr. Natale do my ablation. Got an interesting response from him. He stated he's very aggressive, and well known. He didn't give a glowing review or a negative but stated hes aggressive multiple times. My EP said if my heart is set on a RFA Dr. Robert Rho worked with Dr. Natale and hes local. Needless to say my local EP seems skeptical and discounted any advantages of traveling to Texas for a procedure in the future. I explained were I'm getting my information and of course he went high and mighty on me, "your getting your information/advice from the internet, from people whom aren't trained EP's.

My local EP is still willing to be my local guy if I ever get approved to go to Texas. He's going to really start spelling it out for the insurance that this procedure in fact is medically necessary. He sure did have some skepticism about going to Texas.

I still have great hope of a Dr. Natale ablation in the future. Luckily as of now I'm not terribly symptomatic.

Kevin

What reason was given for the denial? Is it because it's out of state or are they saying it's not necessary?

Whenever I hear an EP label Natale as "aggressive" I write that EP off. It's nothing but jealousy. When I informed my local EP that I was going to have an ablation with Natale, he immediately said I'd made an excellent decision. And he's no slouch himself. He was the director of electrophysiology at Yale University, has done thousands of afib ablations, and is very highly regarded. He had every reason to be jealous, but he wasn't, and that's why he remains my local EP today.

Natale is as aggressive as he needs to be to solve the problem. No more, no less. His track record speaks for itself and your local EP can't even begin to match it. And that's not getting information from the internet; Natale has published numbers.

Not medically necessary was what insurance used as denial.

It was a weird vibe almost as if I was ridiculous to go all the way to Texas with locals EP's that could help. He also said he was surprised Dr. Natale took my case.

You have a documented diagnosis of afib, right? In 2019 that's all that should be required to make an ablation medically justified. Ablation is now considered a first line treatment.

Who actually submitted the request to your insurance company? Was it TCAI? If so, talk to them and see about resubmitting the request. If Natale agreed to do your ablation then it is medically justified.

And frankly, I'd quit talking to your local guy about ablations. His ego is too fragile. Use him for meds or whatever you need, but just skip the ablation talk.

Medicare approves ablation for AF so everyone else should too. That’s pretty much the standard in this country. It used to be that you needed to fail on two medications first but I don’t think that’s true anymore. Even if it were that’s not hard to do for most afibbers.

Who is the insurer?

TCAI submitted the request and appeal as well. My insurance set up a peer to peer but unfortunately TCAI had no one available at the times my insurance called them.

Ya my local EP has now been officially benched as far as ablations go. Last visit he had made mention he wasn't sure why people still do RFA anymore. He's a high volume ablationist at UW Medicine.

Regence is my insurance. I have had documented 8 yrs with my local guy. Failed multaq, rytmol, and now appear to be showing signs this year of break throughs with flec/met.

Said I have to meet one of the following:

Intolerance to rate control medications
 Accessory pathway identified
 Patient has hypertrophic obstructive cardiomyopathy, and rhythm control
with medication has failed, is not tolerated, or is not preferred.
 Patient with tachy-brady syndrome (e.g., as alternative to pacemaker
implantation)
 Symptomatic paroxysmal atrial fibrillation, and rhythm control is desired
(i.e., in addition to rate control)
 Symptomatic persistent atrial fibrillation and ALL of the following:
 Rhythm control desired (i.e., in addition to rate control)
 Rhythm control is judged to be feasible (e.g., absent or minimal
left atrial enlargement).
 Antiarrhythmic medication has failed or is not tolerated.
This decision applies to the service requested above and all services, equipment or supplies

Your insurance company is jacking you around. How is it you don't meet this criterion?

Quote

Symptomatic paroxysmal atrial fibrillation, and rhythm control is desired
(i.e., in addition to rate control)

Quote
Carey
Whenever I hear an EP label Natale as "aggressive" I write that EP off. It's nothing but jealousy. When I informed my local EP that I was going to have an ablation with Natale, he immediately said I'd made an excellent decision. And he's no slouch himself. He was the director of electrophysiology at Yale University, has done thousands of afib ablations, and is very highly regarded. He had every reason to be jealous, but he wasn't, and that's why he remains my local EP today.

Natale is as aggressive as he needs to be to solve the problem. No more, no less. His track record speaks for itself and your local EP can't even begin to match it. And that's not getting information from the internet; Natale has published numbers.

When I told my EP that I was planning a trip to Texas to see Dr. Natale he was not only impressed that I was able to get an appointment with him. He also offered to assist in any way he could to get me there short of paying my way. Ego's should play zero part in your health care.

Quote
rocketritch
Ego's should play zero part in your health care.

How true, but not always the case. Have a family member with a glioblastoma brain cancer. A doc at MD Anderson in Houston is directing their care. The family recently moved to Denver and needed local docs, too. Met with a team a the University Hospital. They could not have been more supportive and were happy to execute the plan presented by MD Anderson. It was very refreshing and a wonderful example of what health care should be - a truly collaborative effort with the patient's best interest at heart.

I am not saying Natale is doing anything wrong, but my take on Natale was that he is aggressive. That his scheme of handling things was aggressive compared to other Ablationists. I am not an expert on Ablationists, but I can see why others might draw that conclusion, and I don't think it's just because of Jealousy.

Quote
The Anti-Fib
I am not saying Natale is doing anything wrong, but my take on Natale was that he is aggressive. That his scheme of handling things was aggressive compared to other Ablationists. I am not an expert on Ablationists, but I can see why others might draw that conclusion, and I don't think it's just because of Jealousy.

Calling him "aggressive" is meaningless. I know of people who've had ablations by him that took minutes and involved no more than 2-3 burns. That's all he did because that's all that was needed. And when you look at his track record of success, particularly with longstanding persistent afib, which the average EP won't even attempt to ablate, I really can't think of any explanation why another EP trained in the same field would make such an unprofessional comment other than jealousy.

I guess it hinges on what he means by aggressive? Does he mean that he does stuff that other EPs are disinclined to do because of lack of experience etc. Or does he mean that he does stuff that other EPs think are unwise? We'd have to have an example of something that's considered "aggressive"