Craig and Kerry Snell of Boiling Springs have been married 20 years and have two children. Kerry will tell you that sitting still is not an option for Craig, but he didn’t have a choice after a stroke in March 2016 left him with locked-in syndrome.
“These people are completely aware of everything that is going on around them but they are unable to communicate or move,” said Kerry Snell.
For three months, 43-year-old Craig was trapped in his body, able only to move his eyes.
“I used to make lists where I had been, which states, and pretend to write them down,” said Craig Snell. “In my mind, I was elsewhere.”
“It was most likely he would never get any better than that, but Craig doesn’t believe those kinds of things,” said Kerry Snell, patting her husband’s knee.
Kerry decided to bring her husband home.
“That was a big decision because it was a lot of work,” she said. “Most people I know go to a nursing home, and I didn’t want to do that because he was too young. It was eight months until I think he could start talking again.”
Thanks to physical therapy, Craig started taking steps again.
“He surprised both of his neurologists, his general practitioner, and even his physical therapist,” said Kerry Snell. “He went from walking in the end of July with a walker and a therapist 26 feet to 190 feet now.”
“It’s a bit of an improvement,” said Craig Snell.
Initially, Craig’s physical therapy sessions were covered by insurance, but when Kerry’s insurance changed, they started getting denial letters saying physical therapy for Craig was no longer covered, although her plan provides 30 visits a year.
She appealed and the insurance company partially denied the claim, stating Craig’s physical therapy did not “satisfy the criteria for establishing medical necessity.”
Kerry decided to appeal again and this time, Craig’s physical therapist and two doctors sent letters of support, saying that “he would benefit from continued physical therapy”, that “he has shown tremendous progress”, and that it is “imperative to improve this patient’s quality of life.”
Again, the claim was partially denied.
The insurance company denying the visits sets off a chain reaction.
“Because Highmark is denying his physical therapy visits, Gateway can’t kick in. I have to use up all of the visits in my plan before Craig can use the Gateway Health Plan,” said Kerry Snell.
Craig still needs assistance to get in and out of the hospital bed set up in the Snells’ home. When he is not in the bed, he uses a motorized wheelchair to move around.
The Snell’s have one last option. Consumer protections that came with the passage of the Affordable Care Act give consumers the right to an independent external review.
“So, a party that doesn’t work for your insurance company, who has independent medical expertise, can review and ultimately decide whether or not that claim should be paid. Now that is not always, unfortunately, a fast process. That final review being independent is binding,” Pennsylvania Insurance Commissioner Jessica Altman said.
Due to HIPAA privacy laws, Highmark could not discuss the Snell’s case.
“We are a clinically led organization with a medical policy team that uses national standards and best practices to guide their work. Every Highmark member is unique and often, so are their circumstances, but I can assure you we put the member first as we make these policy decisions,” said Leilyn Perri, a Highmark spokesman.
The Snells are now in the independent review process.
“Instead of spending my time helping him or helping my kids, I am spending time on the phone arguing with them and writing appeals,” said Kerry Snell “It’s so frustrating because everyone is working towards Craig’s recovery and then Highmark is going to tell us they don’t want to be a part of that.”
Insurance Commissioner Jessica Altman discusses your rights and how the insurance appeals process works in the video below.