Insurer Denies Surgery To Fix Complication From Gunshot Injury
Recently divorced and facing financial trouble, Joseph Pero was in a self-described “dark place” in 2017. Then, he did the unthinkable and pointed a handgun at his own heart. Thankfully, he missed. Instead, the bullet hit his lungs and fractured six ribs. In that moment, Pero realized that he wanted to live. The Los Angeles Times reported on his story.
A year later, Pero’s doctors determined that two of his six fractured ribs were not healing correctly on their own. The injury was causing Pero great pain. His doctors recommended a surgical rib fixation, or rib plating, to heal the injury.
Denver Health, where Pero was being treated, is one of the country’s leading providers of the procedure, performing about 3,000 such operations annually. The Mayo Clinic says that “surgical stabilization of fractured ribs is becoming more widely accepted,” especially for patients with two or more fractured ribs.
However, Pero’s insurer, Aenta, denied coverage for the procedure. Aetna said they only deem the procedure medically necessary when a patient cannot breathe on their own, is unable to come off a ventilator or needs their chest opened for a reason such as lung surgery.
“Aetna considers internal fixation of rib fractures experimental and investigational for all other indications,” the company ruled.
Pero appealed the decision and had his doctor submit a letter of medical necessity, highlight his chronic pain. Again, the surgery was denied.
In January, Pero went to the hospital for difficulty breathing. At the ER, he was told that could expect similar symptoms for the foreseeable future. Frustrated, Pero told Denver Health that he would pay for the rib fixation on his own.
“I’m in incredible pain,” he said. “At this point, I’m looking at taking out a loan and paying for the surgery in cash.”
Pero worked out an out-of-pocket cost and payment plan with the hospital. He expected to pay $8,000 up front and then monthly installments for the roughly $30,000 surgery.
Frustrated by the situation, Pero reached out to the Los Angeles Times. When the paper contacted Aetna, the insurer said they had reversed their decision two days earlier and the news had yet to reach Pero. When Aetna informed him that they would cover the surgery, they made no mention of the previous denials.
“I’m thrilled that they’re going to cover it,” Pero told me, “but I can’t believe what I had to go through to get there.”
He added that when he spoke the other day with an Aetna rep, “the first words out of her mouth was that she understood I’d spoken with a reporter.”