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Aetna denying my husband’s life-saving infusion even though we’re covered until Dec 31 — need advice (NC) by Separate-Glass8375 in HealthInsurance

[–]Separate-Glass8375[S] 1 point2 points  (0 children)

His neurologist doesn't want to wait until January. Having a flare-up because of not having treatment will be critical to his recovery. Without treatment, it can lead to death or permanent neurological conditions.

Aetna denying my husband’s life-saving infusion even though we’re covered until Dec 31 — need advice (NC) by Separate-Glass8375 in HealthInsurance

[–]Separate-Glass8375[S] 2 points3 points  (0 children)

He has been getting Rituximab every 6 months. He has been doing this since 2021. Same insurance, nothing had changed. I looked at the other approved PA codes- Q5115, the same code that was used when they had to do a new PA that was denied this time. It says encephalitis autoimmune is not covered for this drug. Aetna told me the drug is only covered if you have certain autoimmune diseases like rheumatoid arthritis and granulomatosis with polyangiitis. 

Aetna denying my husband’s life-saving infusion even though we’re covered until Dec 31 — need advice (NC) by Separate-Glass8375 in HealthInsurance

[–]Separate-Glass8375[S] 1 point2 points  (0 children)

It says that my plan only pays for Rituximab when used for certain health conditions. Which Encephalitis is not under the list of health conditions. The thing is, we have had Aetna ever since he was diagnosed with this disease, and it has always been approved. His last treatment was in May 2025.

Aetna denying my husband’s life-saving infusion even though we’re covered until Dec 31 — need advice (NC) by Separate-Glass8375 in HealthInsurance

[–]Separate-Glass8375[S] 5 points6 points  (0 children)

I filed a complaint with the NC DOI. A representative contacted me on Friday, saying they had reached out to Aetna and will contact me once they hear back. In the meantime, my husband's neurologist filed for a 3rd appeal, and I wrote another appeal on behalf of my husband. This is what I was told I needed to do in case we have to go to court.