Insurance Denies Coverage for Scoliosis Surgery
Anne-Marie Hukried has repeatedly pushed back against her insurance company’s decision to deny coverage for her daughter Vivian’s scoliosis surgery. This is the third time she has challenged the ruling.
Each time, the outcome has been the same. Aetna maintains that the surgery recommended by doctors for Vivian, who is just 12, is deemed experimental due to insufficient evidence about its long-term safety and efficacy.
With just days before the scheduled surgery on November 11, the family decided to put it on hold, as the cost could reach $100,000 out of pocket.
Living in Centennial, Colorado, Hukried has exhausted her final appeal, leaving Vivian’s critical treatment window narrowing. It’s essential to conduct the surgery while the child is still growing, and girls typically experience their growth peak between ages 10 and 14.
“It’s really disappointing and frustrating,” Hukried expressed. “You feel angry about this. We pay a hefty premium for insurance coverage,” she added.
Scoliosis is an abnormal spinal curvature primarily identified during adolescence, with around three million new diagnoses made every year. Most cases are mild and not symptomatic, but moderate to severe instances can produce back pain, respiratory issues, and decreased mobility. Vivian’s condition, characterized by a spinal curve that resembles a question mark, makes activities she loves, like dancing and attending school, painful.
“There’s so much I struggle with because of my back,” Vivian mentioned. “I genuinely want to keep dancing, and I believe the surgery could really help with that.”
With her dance competition season fast approaching in January, Hukried decided to take legal action against Aetna, filing a lawsuit in a Colorado district court to contest the denial.
Aetna responded in a statement, reaffirming its commitment to helping physicians navigate patient care decisions based on the best available medical evidence, including peer-reviewed research.
While the company did not address NBC News’ inquiry concerning the lawsuit, it did emphasize that a team of clinical experts had determined that the vertebral body tethering (VBT) procedure was outside the standard of care for a 12-year-old with scoliosis. Aetna also referenced data suggesting higher complication rates and worse outcomes with VBT compared to traditional spinal fusion.
The VBT procedure, which doctors recommend for Vivian, involves attaching flexible cords, known as “tethers,” to the vertebrae along her spine’s curve. As she grows, these tethers aim to straighten the curvature by regulating growth on one side and promoting it on the other.
The FDA approved the tether in 2019 for pediatric patients with progressive idiopathic scoliosis, labeling the potential benefits as outweighing risks. The Scoliosis Research Society and the North American Pediatric Orthopedic Association both advocate for insurance coverage of the surgery, yet many insurers, including Aetna, still consider it experimental.
The ongoing struggle for coverage reflects a broader trend where insurers hesitate to adapt their policies to accommodate new medical advancements. Numerous individuals have reported dedicating hours weekly to disputing these denials.
Dr. Daniel Hornschemeyer, a pediatric orthopedic surgeon at the University of Missouri Health Care, lamented the denial’s impact on ideal candidates like Vivian who genuinely need this surgery. His role as an educator and speaker for Highridge College highlights his commitment to evolving surgical practices.
With denials like Aetna’s becoming increasingly prevalent, many are left fighting for the care they need, often at great emotional and financial cost.
