Tuesday, September 22, 2009

United Healthcare's new FAI Ruling

It has been brought to my attention that UHC has made a ridiculous ruling, basically trying to screw us all out of getting our symptomatic hips fixed and allowing us to return to a normal life. I am currently compiling information to prove that their ruling is wrong, unfair, and based on a small number of articles which state that further research needs to be conducted in FAI. they neglected to include the other articles which show that FAI surgery is successful. Below is their take on the issue. Please feel free to write, call, email etc the people at UHC and voice your opinion. If you would like the names of specific people to email (i.e VP and president of HR, medical director), please email me, or leave your email in the "comments" section of this post.


This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.
Confidential and Proprietary, © UnitedHealthcare, Inc. 2009
Femoroacetabular Impingement Syndrome
Type
Technology Assessment
Number
2009T0530A

Approved By
Approval Date
Medical Technology Assessment Committee
8/20/2009

Description
After evaluating relevant benefit document language (exclusions or limitations), refer to Coverage sections of this document to determine coverage.
This policy describes surgical treatment for femoroacetabular impingement (FAI).
Coverage
All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.
Coverage RationaleSurgical treatment, both arthroscopic and open, for femoroacetabular impingement (FAI) syndrome is unproven. This includes the arthroscopic or open procedure itself, removal of any bony and soft tissue pathology including resection of excessive acetabular bone coverage, resection of femoral head-neck junction, labral repair with or without grafting, and debridement or shaving of articular cartilage. At the present time, there is insufficient evidence of long-term efficacy and safety. Long-term, randomized controlled trials are needed to help clinicians better understand the diagnosis and make effective recommendations for treatment.Centers for Medicare and Medicaid Services (CMS): Medicare does not have a national coverage policy for femoroacetabular impingement surgery. Local Coverage Determinations (LCDs) does not exist at this time. Accessed May 11, 2009.
Regulatory Requirements
U.S. Food and Drug Administration (FDA): Although arthroscopic hip surgery for FAI is a procedure that is not subject to FDA regulation, devices and instruments used during the surgery require FDA approval. A search of the FDA 510(k) database revealed over 500 arthroscopes approved for marketing (product code HRX); however, the available studies did not provide sufficient information to determine which 510(k) approvals correspond to the instruments used.Additional information is available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm Accessed August 3, 2009.
Research Evidence
BackgroundFemoroacetabular impingement (FAI), formerly called acetabular rim syndrome or cervicoacatebular impingement, is the main cause of early damage to the acetabular labrum and articular cartilage of the hip, particularly in young, active patients and high-level athletes. In patients with FAI, limitation of both flexion and internal rotation occur at the hip joint as a result of premature pathologic contact between the skeletal prominences of the acetabulum and the femur. FAI generally occurs in one joint; however, in rare cases both hips can be involved. Surgical treatment has been utilized to improve the clearance for motion at the hip joint and lessen the femoral thrust against the acetabular rim. If left untreated, FAI may lead to osteoarthrosis of the hip. (ECRI, 2008)FAI is common in patients presenting with low back pain, cartilage damage, hip pain, loss of range of motion, disability, and sport hernias. Most patients can be diagnosed with a good history, physical examination, plain x-ray, and magnetic resonance imaging. The three types of FAI include the following (ECRI, 2008; NHS 2007): 1) cam impingement due to an aspherical portion of the femoral head-neck junction (i.e., femoral cause) which is most common in young athletes;2) pincer impingement due to focal or wide-ranging excessive coverage of the ball or femoral head (i.e., acetabular cause) which is most common in athletic, middle-aged women; 3) mixed pincer and cam impingement which is the most common type of FAI. Clinical EvidenceA systematic review by Bedi et al. (2008) reviewed 19 articles to determine the quality of the literature assessing outcomes after surgical treatment of labral tears and femoroacetabular impingement (FAI), patient satisfaction after open or arthroscopic intervention, and differences in outcome with open or arthroscopic approaches. The studies reviewed support that 65% to 85% of patients are satisfied with their outcome at a mean of 40 months after surgery. A common finding in all series, however, was an increased incidence of failure among patients with substantial pre-existing osteoarthritis. Arthroscopic treatment of labral tears is also effective, with 67% to 100% of patients being satisfied with their outcomes. The authors concluded that the quality of literature reporting outcomes of surgical intervention for labral tears and FAI is limited. Although open surgical dislocation with osteoplasty is the historical gold standard, the scientific data does not show that open techniques have outcomes superior to arthroscopic techniques.In a prospective observational study, Tanzer and Noiseux (2004) examined the role of FAI in hip disorders. For this study, 38 patients who had labral tears detected during hip arthroscopy and who had radiographic evidence of FAI were followed prospectively after arthroscopic removal of the torn portion of the labrum. Labral tear development was acute as evidenced by a twisting episode or well-defined precipitating event for 19 (50%) patients, insidious or gradual onset of worsening symptoms for 12 (32%), and due to major trauma as evidenced by a violent impact or dislocation for 7 (18%). In 16 (43%) of these patients, arthritic changes were identified on radiographs taken after arthroscopy. Damage associated with acetabular tears included femoral or global arthritic changes in 7 (18%) patients, anterior acetabular arthritic changes in 6 (16%), and femoral chondral lesions in 3 (8%). At 1 year of follow-up of 24 (63%) patients, mechanical symptoms had resolved completely in all patients; however, only 6 (25%) of these patients no longer had pain. The authors concluded that although arthroscopy for hip impingement is promising, future studies are needed to determine if correction of the anterior hip impingement, early in the natural history of the disease, may delay or prevent end-stage arthritis. This study is limited by small sample size with short term follow-up and a non controlled study design.In a prospective study by Peters and Erickson (2006), 30 hips (29 patients) with femoro-acetabular impingement underwent debridement through a greater trochanteric flip osteotomy and anterior dislocation of the femoral head. Cam (femoral based) impingement was noted in 14 hips; pincer (acetabular based) impingement in 1hip; and combined cam and pincer impingement in 15 hips. Mean patient age was 31 years. The mean duration of clinical and radiographic follow-up was 32 months. All patients were followed according to a prospective protocol, with Harris hip scores and plain radiographs obtained preoperatively and at 6 months, 1 year, and annually for a minimum of 2 years. The mean Harris hip score improved from 70 points preoperatively to 87 points at the time of final follow-up. In 18 hips, severe damage of the acetabular articular cartilage that had not been appreciated on preoperative plain radiographs or magnetic resonance arthrography was noted on arthrotomy. Eight of these 18 hips subsequently had radiographic evidence of progression of the osteoarthritis, and 4 of the 8 hips required or were expected to soon require conversion to a total hip arthroplasty to treat progressive pain. The authors concluded that surgical dislocation and debridement of the hip for the treatment of femoro-acetabular impingement in hips without substantial damage to the articular cartilage can reduce pain and improve function. This study is limited by its uncontrolled study design and small sample size.Sampson (2005) conducted a retrospective study of arthroscopic hip surgery for FAI, which reported results for 156 patients, some of whom underwent bilateral arthroscopic surgery. The ages of these patients ranged from 14 to 75 years, and most were between the ages of 20 and 40 years. Symptoms were generally mild and included somewhat reduced range of motion (ROM), poor tolerance of prolonged sitting, and inability to participate in sports. For the majority of patients, pain relief was 50% in 6 to 12 weeks, 75% in 5 months, and 95% in 1 year. Patients no longer needed crutches after 2 to 4 weeks. After follow-up ranging up to 22 months, 3 (2%) patients opted for total joint replacement due to continued pain. The average follow-up period and protocol for follow-up were not reported. This study is limited by its retrospective design, heterogenous patient population which limits the generalization of this data to other populations or who is best suited for the procedure, and lack of defined follow-up period and protocols.An uncontrolled study by Larson and Giveans ( 2008) on 96 patients (100 hips), was conducted to evaluate the early outcomes of arthroscopic management of femoroacetabular impingement (FAI). There were 54 male and 42 female patients with a mean age was 34.7 years. The surgical procedures performed were 26 (26%) proximal femoral osteoplasties, 21 (21%) acetabular rim trimmings, and 53 (53%) combination osteoplasties and trimmings. Patients also underwent labral debridement and repair or refixation as needed. At a mean of 10 months follow-up compared with baseline, mean pain score decreased from 6.7 to 1.9, mean Harris Hip score increased from 61 to 83, and mean SF-12 quality-of-life score increased from 60 to 78. All of these improvements were statistically significant (P<0.001). n="19" name="
References and Resources
ResourcesAmerican College of Rheumatology (ACR) [website]. Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43(9):1905-1915. Available at: http://www.rheumatology.org/publications/guidelines/oa-mgmt/oa-mgmt.asp?aud=mem Accessed June 1, 2009.Bedi A, Chen N, Robertson W, Kelly BT. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy. 2008 Oct;24(10):1135-45.ECRI Institute. Hotline Response. Surgical Treatment of Femoroacetabular Impingement. June 2008.Hayes, Inc. Health Technology Brief. Arthroscopic Hip Surgery for Femoroacetabular Impingement (FAI). Lansdale, PA: Hayes, Inc.; July 18, 2008.Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-RodrE, Camacho-Galindo J. Arthroscopic treatment of cam-type femoroacetabular impingement: preliminary report at 2 years minimum follow-up. J Arthroplasty. 2008;23(2):226-234.Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy. 2008;24(5):540-546.National Institute for Health and Clinical Excellence (NICE). Open femoro-acetabular surgery for hip impingement syndrome. Interventional Procedure Guidance 203. London, UK: NICE; January 2007a. Available at: http://www.nice.org.uk/nicemedia/pdf/IPG203guidance.pdf Accessed May 1, 2009.National Institute for Health and Clinical Excellence (NICE). Arthroscopic femoro-acetabular surgery for hip impingement syndrome. Interventional Procedure Guidance 213. London, UK: NICE; March 2007b. Available at: http://www.nice.org.uk/nicemedia/pdf/ip/IPG213Guidance.pdf Accessed May 1, 2009. National Library for Health (NLH). NHS Evidence. Surgery for Femoroacetabular Impingement. 2007. Available at: http://www.library.nhs.uk/trauma_orthopaedics/viewResource.aspx?resID=269337 Accessed June 1, 2009.Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and din young adults. J Bone Joint Surg Am. 2006 Aug;88(8):1735-41. Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.Philippon MJ, Stubbs AJ, Schenker ML, Maxwell RB, et al. Arthroscopic Management of femoroacetabular impingement; Osteoplasty technique and literature review. Am J Sports Med. 2007; 35(9):1571-1580.Sampson TG. Arthroscopic treatment of femoroacetabular impingement. Tech Orthop. 2005;20(1):56-62.Stahelin L, Stahelin T, Jolles BM, Herzog RF. Arthroscopic offset restoration in femoroacetabular cam impingement: accuracy and early clinical outcome. Arthroscopy. 2008;24(1):51-57.Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop Relat Res. 2004;(429):170-177.
History/Updates
9/1/2009
New Policy.
Coding

The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.CPT Codes:
27299
Unlisted procedure, pelvis or hip joint
29999
Unlisted procedure, arthroscopy

33 comments:

Maria said...

Great information, Susie. It seems a bit odd that UHC would be the only major insurer not covering this procedure as Cigna, BCBS, Kaiser and Regence now pay it. Cigna and BCBS have also just recently changed their procedures.

Anonymous said...

i think my insurance is managed by UHC...
i am guessing this is a new ruling and they maybe payed in the past?
so now that they won't pay for fai surgery...i sincerely doubt they will cover a capsule shrinking procedure! i bet my surgery gets cancelled !
soccermom

Kate.Mich said...

Does UHC have anything to do with Harvard Pilgrim? I am about to begin a battle with Harvard Pilgrim as they do not cover hip scopes for FAI. I have yet to find any information as to whether they cover open surgery or hip scopes from labrum tears. Any ideas?

-Katie

Susie said...

soccermom, I think you will be ok! I have not gotten clear info on what exactly this means, whether it will be covered or not. I am having a really busy week but am doing my best to find out.
Kate- I have no idea what Harvard Pilgrim does, but if you join the FAI yahoo group, there is a link under "files" that contains tons of articles supporting the surgery. I am going through these in order to write a letter to UHC in hopes that they change this policy. Once it is done I will post it here for every to see and have use of.

Maria said...

Harvard Pilgrim and UHC. I found a link:

https://www.harvardpilgrim.org/portal/page?_pageid=253,202302&_dad=portal&_schema=PORTAL

I would like to let you know though that I had an external review for my claim for FAI scope against UHC and the external reviewer called UHC's initial decision as "unethical" and "arbitrary". They had to pay it.

SK_NYC said...

God bless you for your Blog! I have been suffering from constant hip pain for several years. Previous 3 ODs had no idea what was wrong with me except they suspected a labral tear and recommended surgery (not a confirmed tear but suspected but they wanted to go in there anyway!)

Finally the recent OD X-rayed my hips and diagnosed FAI. I have my MRA next week and I am already bracing for the pain.

Thank you for the info on UHC as sadly, I am under the same insurance provider.

Does this mean your procedure was not covered? If UHC won't cover this surgery I won't be able to afford it. Alas, I was so excited about the possibility of pain free living.

Susie said...

Sk-NYC- We are not quite sure what this means, although I was told last night that a friend of a friend did not get his surgery approved because UHC deemed it experimental. The best advice I can give right now is not to give up, try as hard as you can to get the surgery scheduled and approved. Speak to your surgeon about it. Also, the report that UHC put out states 2 codes, it is possible to use other codes, again, I have no idea if this will work or not but hopefully we can make UHC realize that they have made a huge mistake on this. A list of CPT codes that were used for my surgery is available on my blog http://susie711.blogspot.com/search?q=icd9

Do you live in NYC? Just curious bc you mentioned you are having an MRA, if you do, you may want to look into a less invasive, higher resolution 3T MRI.

Kim said...

Hi Susie,
Have UHC and will write and follow up. Email is hornison@aol.com
Thanks for the great info and this blog.

SK_NYC said...

Thanks for the info Susie. Yes I am located in NYC. I have no details on the MRA except for what was written on the prescription which only states MRA hip with lidocaine injection. My OD said this radiologists is familiar with FAI so he will know what to look for. What do you suggest? I have my MRA tomorrow and want to make sure I go in there with some knowledge.

Also, do you know of any experienced ODs in the area that treat FAI? Perhaps it not even FAI, the OD diagnosed it through the xray which states mild pincer and cam (can't be mild bc I am in pain everyday and now its reached my back).

Center edge angle is about 30-32 in terms of the Cam impingement lesion alpha angle is approx 65 degrees.

No idea what this means...

Susie said...

SK-NYC- I would make an appointment with Bryan Kelly at HSS ASAP 212-746-5348. He is in network with UHC so that is a big plus for you! (Don't wait for the results, just get an appt bc it can be a while before there is one available), he is THE one to see in NYC for this problem

SK_NYC said...

Thanks. I tried Doctor Kelly at HSS. Unfortunately, the minimum wait is 3 months for an appointment and thats not even guaranteed. Basically what the secretary told me was that I provide my info and then Dr Kelly will review and determine if and when he will see you. This is consistent with my previous experiences with top rated Doctors...long wait and once you see them, they spend very little time with you and tend to be dismissive of your symptoms. My level of pain doesn't correlate with what they can "see".

Susie said...

SK-NYC- I think it is still worth it, and it may not be 3 months since you live locally, you can probably take a last minute cancellation. Email me if you want, this is a topic I feel really strongly about. I see him and would never see anyone else. suzq613@aol.com

anna from omaha said...

Oh my god! I thoutht I was the only one with this problem. Ive been fighting with uhc since aug!!! Im so upset I cant do anything as Im in so much pain!! I may even lose my job because they wont cover the scope! I just spoke to my doctors office and my doctor is meeting with the medical director of uhc on monday! See what happens!

Susie said...

Anna- good for your surgeon. We all need to make our voices heard on this matter. Please please let us know what happens at this meeting as we would all like UHC to change their policy on the matter. Best of luck to you.

ANNA...FROM OMAHA said...

JUST SO EVERYONE KNOWS. MY DOCTORS OFFICE CALLED ME AND ADVISED ME THAT UNITED HEALTHCARE CANCELLED THE MEETING WITH MY DOCTOR 5MIN BEFORE THE MEETING!!!! MY DOCTOR WAS VERY MAD, IS WHAT THE NURSE TOLD ME! MY WORK SAID I SHOULD CONTACT THE TODAY SHOW OR SOME NEWS CHANNEL. NOT IF THAT WOULD DO ANY GOOD? MAYBE IF A GROUP OF US GOT TOGETHER SOMEONE MIGHT LISTEN.

Susie said...

What jerks! Was he able to re-schedule? Anna, would you consider writing up your story and I can post it as a guest post, so ppl can see what the repercussions of this are? I think a great way to approach this is possibly contacting a station that has had a story on successful FAI surgery and having them show that a company like UHC is not covering your surgery. If you want you can email me suzqa613@aol.com

Tim said...

I had arthoscopic hip surgery for a labral tear and fai on 9/15. I also have UHC, so far they have paid the largest bill (surgery center)and anesthesiologist in full, however have not paid a large porton $3600 of the surgeon's bill. I called the UHC claim department and was informed not to worry about the unpaid balance and I would not be responsible for it. (which is hard to beleive!!)

Anna from omaha said...

Tim how were you able to uhc to cover it?? Ive been denied the surgery because they dont cover scope of the hip?? please tell me your secret? Im in 2nd appeal which goes to my employer and they hash it out with uhc.
Any info from you would be great!!
thanks

Susie said...

Tim, next time you speak with UHC can you please ask them to tel you which CPT codes were billed? I think this makes a difference sometimes.

Anonymous said...

I'm in Nevada and have UHC. My doctor just informed me that UHC is not covering the surgery for FAI. I am so frustrated. After 2 yrs of going to doctors to find out the source of my pain, I find out and it's not covered. There has to be a way to fight this. I will call or write them and my Congressmen, but I feel it will fall on deaf ears.-ic

Susie said...

ic- if you email me (suzq613@aol.com) I can give you specific ppl @ UHC to email/ call, that your doctor can get in touch with as well. You can use articles I have posted to help your fight, but don't back down. There are patient advocates out there that can help you as well.

Tim said...

I am not out of the clear yet even though they paid the hospital bill and anesthesiologist in full, I am on the hook for $3600 for surgery assit and $11,500 for the surgeon. I will request a medical review. To make matters worse my left hip started hurting 10/06/09 and it appears it will need a FAI on it as well.

Anonymous said...

Thank you all for sharing your experiences. My first scope (rt hip) was 9/1, the day UHC changed their med policy. To date, I'm on the hook for about $13K. and they've rejected my second surgery (lft hip), scheduled for 11/13. UHC rejected 5 of my doc's surgeries in one week. He and the clinic are hopping mad. Peer to peer review is their next step, appeal is mine. Not sure i can get it in time for 11/13, but with the success of the first hip, (yes, even at 8 weeks I'm nearly pain free) I might just go for it and deal with the expense later. Crazy?
Buckeyemom

Susie said...

Tim- has it been denied or just not paid yet? Please everyone, appeal, write, call, contact your state board of isnurance, hire a patient advocate if neccessary....don't get stuck with a huge bill when I'm sure, if you are like me, you already pay a fortune to be insured by UHC. The insurance companies want you to just accept their ruling and move on...DON'T

Dharm said...

Okay, I'm now in the same boat. I want to point out though that all UHC didn't pay for me was the surgery to solve the FAI/CAM impingement. So they did pay the entire hospital bill, and I expect them to pay all or most of the anesthesia bill (the facility is in network, the practice that provides all the anesthesia at the facility is out of network). Also they paid the rest of the bill. My doctor's practice made me sign a waiver knowing full well that Aetna, United Healthcare, Cigna, and other companies consider surgery to remove FAI/CAM impingement as "unproven". All is not lost though, the practice will reduce the fee by 50% if the insurance doesn't pay. Given the choice between living in pain and paying $2,500, I would still have made the same decision.

Anna from omaha said...

Good news for me!!!! The company I work for reviewed my claim with uhc and the employee handbook and they approved my surgery!!! Im so thankful for my employer helping me get this surgery. Dec 8 is my surgery date! I sure hope it helps!

Stacey said...

I'm very glad I saw this. I have a hip arthroscopy scheduled in two weeks, and we just got a call from my surgeons office saying that UHC has refused to pay for my surgery. They said there are other options such as physical therapy that would fix my problem. I did physical therapy for 3 months, and it made my pain worse. It seems quite stupid that theyre the only ones refusing to pay for it.

Anonymous said...

Unfortunately, for all of us dealing with the small minded world of the medical insurance companies, UHC is definitely not the only one not covering FAI. I have been in a 1.5 year battle with Aetna about this very thing. I am gathering a "novel" of info to submit with my appeal letter so that whoever it is that is making the decisions about my life can atleast make the decisions based on fact and not how much this is going to cost them...guess what Aetna, it is my life and I want it back!!! Thank you Susie for all your info...this will be really helpful for me. My fingers are crossed for all of us dealing with this condition that the insurance companies think can be fixed by simply becoming stationary...kind of goes again the Obama Administration's mentality that America is overweight mainly due to leading a seditary lifestyle and the only way to fix that is by becoming more active...now they are telling us we need to be less active...someone needs to wake these insurance big wigs up and explain to them that middle aged people don't take being told to stop being active lightly!!! Battle on everyone..Battle one!!!

Tim said...

I just had my 2nd level appeal hearing with UHC today. Great News! They called back within 15 minutes and have agreed to pay for the surgery I had last September.

Susie said...

Tim- that is awesome! I am postin your comment tonight as its own post!!!

mydoll said...

Has UHC changed their tune since this blog? I see a different story in this Medical Policy dated 1/1/11: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Femoroacetabular_Impingement_Syndrome.pdf

We are now battling Aetna for payment, and I found much of this blog helpful, but wanted to see if they changed their tune. The more industry leaders that cover it, the better our case against those that don't.

Mydoll

Lia said...

I just found out I will need this surgery and have UHC. Does anyone know if they pay for it now, I see this post was a few years ago...?

Susie said...

They cover it now