Aetna and FAI 2

A few months ago a fellow hipster sent me a post and asked me to publish it on my blog. It was about Aetna and their refusal to cover FAI surgery. That post generated many replies, including the one below.
This is a response from Aetna:

The date on our website is not the date that the update will be published, but the date that it will be discussed by our Clinical Policy Council. All updates have to go through a subsequent review, approval and implementation process. We expect the update to be published by the end of the year.



Should you have any questions or concerns, regarding these policies contact provider of services dedicated lines; Indemnity and PPO- based benefits plans 1-888-MD Aetna (632-3862) for HMO benefits plans – 1800-624-0756. Our Provider Service Representatives are trained to specifically handle any concerns you may have.



Also, for your convenience any future concerns or questions regarding our policies can also be faxed to us at 859-425-3379.

November 18, 2010 11:56 PM

Below is the original post:
Sent to me by a fellow hip friend:

Aetna’s assessment of FAI is archaic and asinine!

As you all are aware, our cause for UHC’s coverage of FAI was very successful including a NY Times article and many reversed appeals in favor of the patient. UHC along with other major insurers (BCBS, Cigna, Kaiser) now covers the arthroscopic treatment of Femoroacetabular Impingement.


Unfortunately, Aetna still has not caught up with the times. Many of our fellow patients have been successfully treated with hip arthroscopy and have been able to move on to enjoy active lives. People that are insured with Aetna are being discriminated against IF they also have a diagnosis of FAI. Aetna has taken the position that the use of the hip scope is unproven and/or experimental. This is absolutely ridiculous. It is very obvious that the bottom line is that it IS a covered procedure by the other insurers so how is Aetna’s non-coverage of this procedure accurate?



Aetna would rather have a young active patient become so disabled that their medical situation deteriorates to the point of needing a total hip replacement with all the associated medical risks and financial costs. Take the example of your typical patient. Young, active 30 year old Aetna consumer who is denied access to treatment for FAI. Based on Aetna’s opinion, the patient will go untreated for years UNTIL the patient requires a total hip replacement. Of course, doctors won’t typically do a THR on someone under 60 so this patient has to wait 30 years for treatment because of Aetna’s inaccurate and woefully pathetic position on FAI treatment.



Mr. Ron Williams (CEO of Aetna) when is Aetna going to catch up with the peer reviewed literature and your peers? When is Aetna going to reverse the policy so that your clients that need this surgery will have the same rights as patients that have UHC, Cigna, BCBS and Kaiser? When will Aetna decide that they would like the “A” in Aetna to equate to “Amazing” instead of “Awful’?posted by Susie at 7:47 PM on Sep 28, 2010

Double Update

Hip: I had an appt with my hip OS a few weeks ago but haven't had a chance to post yet. I am almost 1 year out from my last (4th) hip scope and very pleased with the results. I have no pain at all in my hip. the only residual effect from that surgery is that my hip is really tight and still catches and pops quite often. I don't care though, I will take that over groin pain any day. My OS explained that during the capsule tightening procedures, sometimes they make it a little too tight, he recommended more PT to keep it loose, since that is what I do when it gets bad, but he would like me to take a more preventative approach with PT and go before it gets bad. In theory, that is a wonderful idea, in reality, who has time for more PT!!! He also offered me a cortisone injection into the capsule, which I politely declined as well...no more hip injections for me! I will deal with this!

Shoulder: It has been 2 weeks since I had the AC joint injected and I am thrilled with the results. The joint does not hurt at all anymore. Although I still get some pain around the area sometimes, It is tolerable. In a very "susie-like" fashion, I requested the OS office note and the radiology report on my x-ray...OS suspects AC joint arthritis, if the injection doesn't help he will order an MRI to rule out osteolysis, which is not a common problem in 30 year old housewives!!!! (ok, I work too, but still...), it is more of a weight lifter issue, and the only weights I lift are 40 lbs toddlers and pots and pans!!!!

Cost of Hip Arthroscopy has been updated

http://susie711.blogspot.com/2008/01/cost-of-hip-arthroscopy-and-its.html


Surgery # 4 numbers have been added...1 year later!! Life has been pretty busy!

Cortisone Injection # ?????

As I had hoped, my "new" OS gave me a cortisone injection. He agreed that whatever my issue is, it is coming from my AC joint. He is not sure what or how I injured it since there was no trauma, but he thinks that given my line of work, it is not too shocking. My x-rays were good, no arthritis or separation, he thinks that it is just a local inflammation and hopefully the cortisone will knock it out.
Most of his pain provoking tests referred pain to the front of my shoulder, at the AC joint, and there is tightness with horizontal adduction. I am pretty sure the cortisone in working, I felt no pain right after which is good since he used some local anesthetic with the steroid when he injected.
I hope to continue to report improvement with the shoulder!

Shoulder...

As my shoulder issue continues to be an issue, I am happy to report that I finally took the time to listen to what my body was telling me and self diagnose!!! I do not have a labral injury or a rotator cuff injury, rather, an acromioclavicular (AC) injury, or, a separated shoulder. Whats funny is that this is usually caused by trauma or a direct fall onto the shoulder....but not me, I just 'develop' these issues! Since it does not seem to be getting better, and I am having trouble sleeping at night and difficulty working, I made an appointment with a shoulder specialist. What a breath of fresh it air to deal with his office...I called Thursday and was given an appointment for Tues...5 days later....I think I waited for my first hip appointment 4 weeks and currently people are waiting 6 weeks or longer to see my OS. So I will hopefully see him tomorrow, hopefully he will give me a cortisone injection and I will be on my way!!!

Massage...Ahhh!!

I went for a 1 hour massage on Tuesday in hopes of leaving a little more relaxed and in less pain. The massage therapist asked if I had any "problem areas", so I told her my right shoulder had been bothering me. She said she would focus a little more on it while she worked.

So the massage began and she began working on my scapula and upper trap, "wow", she said, " this is really bad". She continued for another few minutes, and then said "I think I can spend the entire hour on this shoulder, if you want, or I can leave it if this is too painful for you and do the rest of your body". I told her to just do the shoulder. It was excruciating, every spot on the entire upper right quarter of my body was so painful. There were knots everywhere, she used her elbow, she was dripping sweat halfway into the massage. After the hour was up, she said that it looked better, definitely lower and softer, but she could spend another 2 hours on it if she had the time.

The rest of the day and into the next day were really painful. It hurt to touch the area. By Thursday night it was beginning to feel better. I have had a lot less pain in it and am able to use it more than I was. I am hoping that it was a big muscular issue and I won't be dealing with it anymore. I will keep you updated since I still continue to have pain at night and some of the surrounding muscles still hurt.

Running...Again

I decided to give running one more chance, how bad can it be, I already had 4 hip surgeries, hurt my ankle, peed all over myself and hurt my shoulder...does lightning really strike twice????

So....most importantly, the pelvic floor exercises really worked, no more incontinence on the treadmill!!! This was the main reason I hadn't gone back to running. It was a huge concern of mine and luckily I was able to take care of it. The hips and ankles did great as well. Unfortunately, running bothered my shoulder.....strange as it sounds. At about 22 minutes I gave up completely on running and stuck to walking, I guess the pounding and vibrations seem to upset it too much.

Shoulder Update

For those of you with shoulder issues, please chime in and tell me if any of
this is familiar. I have pain on and off, sometimes I am 100% pain free, other
times I am in agony. I can do anything with it, but will immediately know if I
shouldn't have bc it will hurt. Nights are the worst, sometimes I can't sleep it
is so bad. The pain is usually right at the top/front of the shoulder but will
radiate to the back of my scapula, down my biceps or triceps and into my upper
trap. I guess it depends what I do and how I compensate. I ice, I heat, I
Flector, they help but the pain come back. I am trying to strengthen my rotator
cuff but it is painful and I usually have more pain later in the day when I do.
My ROM is starting to feel limited at endrange, so I am stretching it daily.

So...those are my symptoms. I have also done acupuncture and moxa, acupuncture
didn't help, moxa may have, I just did it last night so the jury is still out. I
just want a quick fix and for the pain to go away!

Shoulder Now.....Please Make It Stop

Very interestingly, a few weeks ago, it was brought up on the FAI yahoo group that many people on the list who have had an acetabular labral injury have also had a glenoid (shoulder) labral injury. While the anatomy of the 2 is very different, the hip is an inherently stable joint and the shoulder is an inherently unstable joint, I found it odd that so many people had both issues. I don't think there is a relationship and I doubt that so many people have any underlying soft tissue pathology, but who knows. Honestly, I think that it has to do with the fact that these types of injuries occur in young and active populations. I didn't think much of it until about 3 weeks ago when my shoulder began hurting...alot.

For the past several months, I have had pain at the top of my shoulder and my upper trap, I attributed it to stress and promised myself that I would schedule a massage. Of course I never found time for a massage so continued to suffer. It was especially bad at night, so I attributed it to my pillow and switched to another one. That didn't help. The pain then travelled into my shoulder joint, into my biceps and posterior scapular muscles. It hurt at rest, more at night, felt weak, at times it is difficult to hold a glass of water or coffee cup. I can do everything with it, and it usually doesn't hurt while I am doing it, but will hurt right after. It feels weak but I cannot pinpoint one spot where the pain is, it is an entire area. The last 2 nights I have slept with a Flector patch on it and it seems to be helping.

Just as the hip issues were beginning to clear up, this happens. I am at a loss with this and don't know what to do.....

Aetna and FAI

Sent to me by a fellow hip friend:

Aetna’s assessment of FAI is archaic and asinine!

As you all are aware, our cause for UHC’s coverage of FAI was very successful including a NY Times article and many reversed appeals in favor of the patient. UHC along with other major insurers (BCBS, Cigna, Kaiser) now covers the arthroscopic treatment of Femoroacetabular Impingement.


Unfortunately, Aetna still has not caught up with the times. Many of our fellow patients have been successfully treated with hip arthroscopy and have been able to move on to enjoy active lives. People that are insured with Aetna are being discriminated against IF they also have a diagnosis of FAI. Aetna has taken the position that the use of the hip scope is unproven and/or experimental. This is absolutely ridiculous. It is very obvious that the bottom line is that it IS a covered procedure by the other insurers so how is Aetna’s non-coverage of this procedure accurate?



Aetna would rather have a young active patient become so disabled that their medical situation deteriorates to the point of needing a total hip replacement with all the associated medical risks and financial costs. Take the example of your typical patient. Young, active 30 year old Aetna consumer who is denied access to treatment for FAI. Based on Aetna’s opinion, the patient will go untreated for years UNTIL the patient requires a total hip replacement. Of course, doctors won’t typically do a THR on someone under 60 so this patient has to wait 30 years for treatment because of Aetna’s inaccurate and woefully pathetic position on FAI treatment.



Mr. Ron Williams (CEO of Aetna) when is Aetna going to catch up with the peer reviewed literature and your peers? When is Aetna going to reverse the policy so that your clients that need this surgery will have the same rights as patients that have UHC, Cigna, BCBS and Kaiser? When will Aetna decide that they would like the “A” in Aetna to equate to “Amazing” instead of “Awful’?

Hip Issues and Incontinence

If you are thinking this is TMI, then I suggest you stop reading. As usual, I have no problem discussing the things that no one else wants to.
When I initially had hip pain, over 3 years ago, one thing In noticed was that I had to do a pelvic floor muscle (PFM) contraction, or kegel, when I would cough or sneeze. I never actually leaked urine but felt that I was going to. With regular PT, this got better and I forgot about it. Last week I was doing jumping jacks with L when I suddenly leaked so much urine that it was running down my legs. I was shocked. I not only had never actually leaked urine, but this was a huge amount, and completely out of the blue. I have been having a lot of tightness in my hip, and even had to go back to PT yesterday for a "tune up", but I see no other reason for this.

At PT, my PT loosened up the anterior capsule for me and sent me on my way, encouraging me to go back to running to keep the hip stretched. I did, last night I got right back on the treadmill and began running. I started feeling leakage again and couldn't believe it, I was leaking urine again. Now, jumping jacks I don't do on a regular basis, but running...I never ever had a problem with running. I am totally freaked out by this. My only saving grace is that I was home both times. Yes, I ahve had 3 babies, 4 hip surgeries, but urinary incontinence is NEVER normal.

So, what am I doing about it? PFM exercises, and more PFM exercises. Kegels when I remember, plus hip adduction (squeezing a ball in between my knees) and hip ER/abd with a theraband around my knees. I am going to do them aggressively, I won't be running for a while because I will be travelling a lot in the next week and a half, but hopefully when I get back things will be strong again and I wont have this problem anymore.

Checking In

Wow, what a slacker I have been! The truth is that I turn to my blog when things are not going well, and well, for the most part they have! I am not running at the moment bc it was bothering my hip, but between you and me, running is probably stupid and I shouldn't be doing it. I also just left my job of 5 years, but decided I wanted to try my new job before quitting, so for a period of time I was at 2 jobs. I am now back down to one job and feeling a lot more calm. As far as my hip goes, it has been tightening up, and the capsule gets caught on something and I experience a lot of clicking. It also gets stuck sometimes and will pop loudly when it finally gets unstuck. I should go back to PT for a "tune up" but haven't had time! I will see how things go, and now that I have more time I will go back to running again, and see how I feel!

5K Training...taking a break :-(

My 5K training has been going especially well, I a quite impressed with myself since I have never been a runner before but mentally really needed something to get me out of the "hip slump".
Last week I ordered a pair of Fit Flops thinking they would be great to help tone up my legs. Well....they were anything but great. I developed horrendous ankle pain, right worse than left. My right ankle is so swollen and painful that there are parts of the day that I think I have a stress fracture. I was wearing socks at Pilates yesterday and the swelling began hanging over the sock...gross!! When I first wake up it feels ok but as I start walking on it I feel it begin to swell and the pain comes back with a vengeance. It obviously doesn't help that I am on my feet the entire time that I am at work. I am hoping that this will go away on its own...not in the mood for doctors and x-rays :-(

When in Doubt, Find An Experienced Surgeon

When I had my appointment with BK, we did some talking about why my surgeries failed and what he has learned, and why his surgeries no longer fail. Unfortunately for me, I got injured 3 years too early. Lucky for everyone else, he too has (and the other "big names") changed his technique. For starters, I could have avoided revision surgery #1 bc now he ALWAYS takes down cam impingement in women. He has found that addressing just a pincer is a big mistake bc women for the most part have larger femoral heads, by doing a rim decompression the problem is just exacerbated. I could have avoided revision #2 bc he now ALWAYS closes the capsule at the end of the surgery, way back when, it was left open. Some lucky few of us subluxed our hips and required the capsule to be tightened (hence the capsular shift I most recently underwent).

What I thought was so interesting was that he was able to just look at my plain x-rays and see that my left was done with the old techniques, and the right with new techniques. He has taken some bone down in each surgery and the final result is a "perfectly shaped" hip on the right! The left looks good, but not quite as "beautiful" as the right, despite the fact that the left NEVER gives me trouble.

"The Recommendation...And What I Am Doing About It

I have been having episodes of groin pain and tightness, definitely better than
a few months ago, but still making me crazy anyway. I just don't want to deal
with it anymore. I saw BK last week, my x-rays look great. Actually, my multiple
scoped hip looks fantastic angle-wise, my single scoped hip doesn't look 'as
perfect' to him, but it is perfect to me! He thinks I should go back to PT to
address my lingering tightness and pain. I agree, but.... I really don't want to
go back to PT! I love my PT but at almost 8 months out, I don't want to continue
or go back. I have decided to work on it on my own and in my craziness I am
starting a 'couch to 5k' program tomorrow. I desperately want to get into an
exercise routine, and have a goal, and be excited to do it. I think this is a
good way. I really hope this won't make my pain worse or my capsule tighter. My
plan is to start tomorrow, if all goes well this week then I will splurge on a
good pair of running shoes next weekend. J is training with me and I think I
convinced my parents too!

Hopefully this can get my past the latest bump in the hip journey!

Am I Micro Managing?

Am I being crazy and unrealistic? Wed I knew I was in for trouble, since I had to go do a presentation at L's school. her school is built on the side of a hill ( a very steep hill). Getting there was no problem, since her classroom is close to the bottom. Coming back up was quite an adventure. I still have a lot of trouble walking uphill. That night I had a ton of pain which I wasn't expecting, and made me quite mad!! I really don't think I should be dealing with pain like this at this point, and quite frankly I need this hip to start behaving!

Time Flies When You're Having Fun...

...Or not!! So once again, it has been a roller coaster of issues with my hip. It is a lot better than before I began this round of PT, the capsule is a lot "looser" and is not getting stuck as often. It does often click or pop. A lot of time I will be trying to shave my legs and the leg just wont externally rotate, it then pops, and is then able to rotate. Weird. What bothers me is that I still get pain in the joint and I don't know why. It is not excruciating, I don't take anything for it, I don't even use the Flector patches on it anymore, I have just gotten used to it I guess. I am at the point where I just give up, at lest for now. I don't think there is anything else to be done at this point, and many people need up to a year to feel better, so maybe I need to have a little bit of patience and wait. This is easier said than done, bc at 29, I don't want to have pain when doing simple activities, like cleaning out my closet, taking the kids for a walk (yes, these are all activities that cause me pain), but I have resolved to "chill out" and give it some time.

My crazy work schedule is coming to an end in 2 weeks, thank goodness, so we will see what happens. I had PT this week, and he managed to really loosen up my hip, and get me to have normal stride length. This lasted a total of 4 minutes. Once I was back outside, walking the streets of NYC, I had pain, which was incredibly frustrating. I have an appointment with BK in a few weeks, mostly to get an x-ray and make sure the bone is where it needs to be. I called about 2 weeks ago (middle of May) to make an appointment, the receptionist asked if I was in pain, I said yes. She told me she would try to "squeeze me in", "how's June 22nd". Seriously!! The truth is that it doesn't even matter bc there is nothing to be done, or at least that I am open to doing (injections, drugs...), but she managed to give me June 15th! I will try to be better about updating my blog, but work is sucking the life out of me!

Yes, I Won My Appeal

Lately I have been receiving comments on older posts asking if I won my appeal. Yes, I did, my surgery was completely covered :-) Thanks to all who have helped me with the appeal as well as paved the way for me and others to have our surgery covered (especially MC)!

A few weeks ago, I had a 20 minute "hole" in my day and was actually able to leave my office for the first time in the middle of the day since I began my new hours. As I was walking out, I realized I had a voicemail from BKs billing office. I called them back to see what they wanted. His biller called to thank me for appealing my claim, she had received the letter a few weeks ago but had only been able to tell BK about it that day. He was very happy told her to call me to ask for a copy of the appeal I used so that it could be used for other patients with the same issue. I hope that it does and everyone who needs the surgery will be able to have it and move on with their life (some of us a little slower than others!!!)

The Exercises

Once again I apologize for taking so long to post, my work schedule is horrendous, and I even had to go in on my day off this week, with the baby no less! I am tired, cranky and counting the days until this is over (Jun 14).

The exercises my PT gave me are not strengthening exercises, in fact, they are just stretching/ mobilizing exercises, and I am supposed to go back to him to get strengthening exercises. (My appointment is 3 weeks from now).

The exercises are meant to keep the anterior capsule stretched out and loose, I don't recommend you do them since most people don't have this problem of soft tissue impingement. The most simple one I do is sit in Indian style (yes, this is how I got into this mess to begin with!!) and put my hands behind me and hold the stretch (I try to hold for 60-90 seconds), if I don't feel enough of a stretch I do a posterior pelvic tilt.

I also do a mobilization with a mob belt, this requires another person. We wrap the belt around my thigh while they sit on a stool and the belt goes around them. Their job is merely to stabilize and provide a tiny bit of a lateral force. I keep my right (bad) leg behind me and stand in a position as if I was going to lunge. I put my arms out in front and rotate my body to the left, so my right leg is getting and external rotation force. This is a very specific an targeted mobilization for the anterior capsule. I am to do this 2x/week.

I can also do a half kneeling stretch but I have chosen not to, since I am getting great results for these 2.

My hip flexion has been as good as 115' degrees, pain free, it does tighten up if I slack off. I felt so great this week I did my first Pilates reformer class and (shhhhh) went Spinning on Fri. I have since tightened up a bit but I really needed that, I think I need to return to exercising as part of this final step in rehab/recovery. I have 2 more Pilates sessions planned for this week and really hope I can spin at least 3x/week for now.

I promise to keep you updated...but please be patient...I have never been so busy and overwhelmed in my life!

Problem Solved....Or So I Hope

I know I am probably jumping the gun, but I definitely feel better mentally about what has been going on. I think I finally have an understanding of what the problem has been, and why I have been having so many issues and problems, and now the final fix will lie with me.

All along, it seems that my capsule has been too tight (since the last surgery), so, as it was explained to me for the millionth time (but this time I 'get it'), imagine that the capsule is like saran wrap, tightly covering the whole hip joint. If it fits well, it will keep the joint in place and allows it to move well through its range of motion. In very rare, super special cases, like mine, it gets too tight, so when I tried to flex my hip, there was no give in the "saran wrap" and it was getting bunched up in the front of the joint. That's why my flexion was so limited, and when I was having the "episodes" and all the clunking, it was the capsule snapping, or getting "unstuck".

The solution was to do some very specific mobilization, we had to tweak them on Friday, but I left PT on Fri so happy! I have had almost no catching/ clunking/ feeling of subluxation since then. I still have pain, but I have increased hip flexion too, so I am happy, and I think I need to be in a good place mentally at this point bc I have been close to losing it more than once.

I have specific stretches to do, to keep the capsule stretched, and twice per week I am supposed to have someone help we with a mobilization using a mob belt. It is an ER mob while my hip is stabilized in extension, it is amazing and works wonders.

I am supposed to begin strengthening in 2 weeks, I can't get back to PT for 4, so I may have to begin on my own. When I overdo the stretching, I can't walk well, and actually have a trendelenberg, bc my hip is not used to functioning in the new range.

I hope things go uphill from here, this is getting very very old!!

I apologize for not being on top of blogging, I am not really on top of anything lately, I have been working crazy hours and most things have fallen to the wayside...my MIL was here for the weekend and re-organized my closets bc they have gotten so messy!!!!

I Have Reached A New Low In Life

Wednesday was my PT session, as I had discussed with BK and my PT at the conference we were at on Friday. The conference lasted 2 days but I was only able to attend the first one. When I arrived to PT on Wed, I told my PT that my friend who had attended both days loved his presentation on the second day. He asked if she had heard the part about the difficult case he has now, who has tightness anteriorly due to a tightened capsule, but laxity posteriorly due to a torn ligamentum teres....hmm, "is that me?" I asked....Yep!! So my all time low is that I am the "difficult" and "challenging" case that is spoken about at conferences.

So PT was good, he thinks that if he mobilizes me anteriorly, it will give me more space and less pinching. I pinch in the front at 90 degrees of flexion, which is very upsetting to me, I would like to have at least 120 degrees of painfree flexion.

He did his thing and I got about 100-110 degrees of painfree flexion. But I was a bit unstable because I was working in a new range that I was not used to. He did a few adjustments, I was sore but felt like we had made progress.

Once I got home I was having tremendous posterior pain, which made absolutely no sense at all. I guess this whole thing makes absolutely no sense at all...so I emailed my PT, who said to hold off on all stretches for now. I see him tomorrow for some more mobs. We spoke this morning again and I apologized for being so high maintenance!! He was going to speak to BK today and try to figure this whole thing out...again!

The Pow Wow

Friday was the ortho conference given by HSS, the keynote speaker was Dr Byrd, which was very cool. Other speakers included BK and my PT. After the hip topic was over, Everyone swarmed over to BK, it was hysterical, he was so popular. He made his way through the crowd over to me, and we had a quick meeting! I said I just want us all to be on the same page about what is going on. So we agreed to try one thing in PT, he promised that if I wasn't getting good results he wouldn't make me do it for a long time, and that if when I am at PT this week, if things don't go well, he will come right over and see what is going on.
So, hopefully PT will be on Wed, and Wed night I will have great things to report!

And the Saga Continues...

Have you ever felt like you needed a time-out from life? I think that is exactly what I need right now. I spoke with BK last night about my ultrasound, he said that, "just as he thought", the problem is that the capsule is thickened and impinging in the joint. He thinks that for now, the solution is anterior hip mobs to stretch it out a little bit and give it more space. This is rather conflicting since prior to the MRI and Ultrasound, my PT wanted to avoid anterior mobs since he felt the joint was a little bit unstable. Now the thought is that it is too tight. See why I need a time-out.
I was emailing back and forth with a fellow hip friend last night, and one of the things she asked is what do I think is going on? Honestly, I have no idea whatsoever, I usually have at least an idea, a thought, something... I am just plain confused now.
The plan is for BK to speak with my PT today and see if he agrees that this 'plan' is a good idea. We are all going to be at an ortho conference on Fri, so the plan is to have a quick little meeting there and discuss this all together.

At this point I don't know how much more of this I can take. I had a mini breakdown last night, because after 4 surgeries, 8 injections, months and months of PT....I am done...I don't want my hip to run my life anymore.

Ultrasound Report

There is mild deep surface fraying of the iliopsoas tendon which is otherwise preserved. No associated iliopsoas bursa is evident. Of note, there is a focal capsular thickening corresponding to abnormality noted on MRI. Area of focal capsular thickening appears to immediately overlie the anterosuperior labrum resulting in mild mass impression on the labrum. No discrete snapping or pain could be elicited with provacative maneuvers.

Impression:
Mild ilipsoas tendinosis with deep sided fraying, right hip.
Focal lateral capsular thickening which appears to impinge along the anterosuperior labrum.

It was elected not to proceed with the ultrasound guided injection today pending discussion with referring clinician.

Sometimes Even I Can't Believe that These Things Happen To Me

Today was supposed to be my ultrasound with 'possible' injection, based on what the radiologist and BK saw on the ultrasound. All was going well, I arrived to the hospital on time, they actually did have the appointment scheduled (which I am always a little shocked at!). Then things started going downhill, and all I can say is that I was fucking pissed.

The radiologist came in and looked at the prescription and chuckled a little, "possible injection?" he asked, so I explained that BK was supposed to be there too, so his assistant called BKs office, who, let me sidetrack for a moment, knew that this was supposed to be scheduled so that he could come, as well as my PT, since I had first told the scheduler and then he did as well. Well, you can imagine my shock when the radiologists assistant reported back to us that BK was on vacation. NFW. Why the hell was this scheduled for today then???? So, as you can see, this is why I am not just pissed, I am fucking pissed.

So the radiologist did the ultrasound, wasn't too interested in hearing what I had to say, or have me explain what exactly happens, and that I can't reproduce it at will. He did say that my psoas is somewhat irregular and the capsule is very thick. I asked if it was thick bc of the capsular shift, he said it was even too thick for that. He said he could inject either the psoas or the capsule or both, but really needed to know what BK wanted. So no injection today.

I left rather pissed off, but treated myself to some retail therapy!

UHC: 0 Susie: 1

I just checked my online EOBs with UHC and my surgery has been PAID for!! Whoohoo!!! They are paying $6750. I have not received anything in the mail yet, like a letter, an explanation, an apology :-) but just decided to have a look online!!!! What a way to start to the weekend!!

Stepping on Glass Was One of The Best Things I Could Have Done

I apologize for going MIA while in MIA! Things were just really hectic and I found it difficult to get to the computer.
My trip began with Z having a horrific diaper rash. As a remedy, I was letting him run around without a diaper. He ran into a corner and decided to poop on the floor. As I went to get him he knocked over a crystal picture frame and it shattered. There was glass everywhere and I just so happened to step on it and cut my foot...badly. So for 2 days I was pretty much homebound since it hurt to walk on my foot. My hip felt great with this rest! The rest of this trip was pretty low key, and as usual, Miami was a great 'cure' for hip pain!

I am beginning to think that the 'episodes' I was having were indeed my psoas doing something funky, but I still am not sure what exactly it is doing. I think that when I flex and feel whatever it is I feel, it is the psoas. I dont know what it is doing or why, or what the solution is, but I don't know if it is subluxing. I guess I am just confused again!

My ultrasound is next week, so hopefully it will shed some light on the matter!

Now Its Tight...

Beginning this week, I have changed my work schedule. I used to work three 5 hour days, 15 hours per week. For the next 3 months, I am working three 12 hour days....I know, a huge change! I have been really concerned about how my hip would hold up. So far it hasn't been too bad. Yesterday it started feeling really tight. My psoas started snapping even more than usual and I was unable to take large steps with my left leg bc the right couldn't go too far into extension. It was so strange, all the muscles just decided that they had had enough with this instability crap and kicked into high gear to protect my hip from sliding around. I hate this tight feeling but I also hate the instability........

Timeline Recap

If you have just begun to read my blog now, it may seem confusing, and you may not know how I got to where I am, and how a 29 year old, otherwise healthy person, can have so many issues with one joint! Here is a link to my "timeline", which when I remember, I update!

Hip MRI #5

Patient is status post debridement of the femoral head enck junction with reconstruction of an anatomical offset. The anterior labrum has been debrided and is diminutive but without tear.
There is irregularity of the anterior joint capsule best appreciated on the oblique axial images, more prominent than previous, perhaps representing the recent anterior surgical approach.

Superior labrum has been debrided since previous and is now deficient. Posterior labrum shows a prominent sublabral foramen, unchnaged from previous.

Sagittal images show irregularity of the cartilage of the anterior aspects of both the acetabulum and femoral head, not significantly changed. There is generalized thinning of cartilage over the anterior aspect of the femoral head best appreciated on the oblique axial images, but also unchanged.

Superior aspect of the acetabular cartilage is preserved. Cartilage over the posterior aspect of the acetabulum is thinned.

Small joint effusion is present.

Negative for greater trochanteric or iliopsoas bursitis.

Signal from bone is normal. The sacroiliac joints are preserved. At L5-S1 there is a focal midline disc protrusion causing mild-moderate central stenosis, unchanged from previous.

Signal from pelvic musculature is normal. There is very mild degeneration of the hamstring origins.

Right hip shows approximately 6 degrees of corrected femoral retroversion. Left hip shows approximately 8 degrees of corrected femoral anteversion.

Impression:
Superior labrum has been debrided since the previous examination. Cartilage wear over the acetabulum and femoral head is unchanged. The increased prominence of the anterior capsular defect most likely represents the recent surgery.

An Answer???? I Think Not!

So I did get a reply to my email which is still not helping me really understand what is happening! There may be "soft tissue(capsule/psoas/scar) pinching in the front of the joint with flexion. Whether it is the psoas getting stuck, or just capsular thickening, or scar, I don't know, that is what I hope to see with the ultrasound".
My problem with all of this is that my psoas snaps, always has...but in extension, not flexion. I don't seem to 'get' what is happening in flexion. Of course it didn't do it while I was there, and I can't reproduce it at will! I haven't had a huge, standing subluxation in almost 2 weeks, which is a good sign, just the sitting one this past week.

My other question was about my increased ER, which is quite excessive. His response was that I have so much ER probably due to the improved offset superolaterally, as seen on my most recent MRI.

So still no concrete answers, which is why I am having such a hard time with this.

The Appointment

I'm not sure how to describe today's appointment. I went with J for moral support because I have been having a hard time dealing with my continued hip issues. Before coming in to see me, BK looked at my MRI and from what I could hear through the door, he was confused by what he saw. He had to call the radiologist to go over it with him.
When he came in to see me, he did some moving of my hip and it clicked, he said that was psoas. I have no pain in ER which again, he found strange. My "secret" PT joined us so we were all able to discuss the situation. BK thinks that based on my MRI, I am having a problem with my psoas. It is getting caught in the joint, this is why I have so much pain, the psoas is inflamed. The reason I have posterior pain is because of the way I am sitting to avoid pinching the psoas. He doesn't think the joint is shifting or subluxing...I don't know if I agree or if I even understand everything he said.
He wants me to get a dynamic ultrasound so he can see exactly what is happening. He would like to try to be there for it, as well as my PT. This should be interesting to schedule!
When we left, I was visibly upset. J wanted to know what was wrong, he thought it had gone very well! I don't know what I thought but I was very confused and didn't seem to understand everything. I still feel like I am missing something...I think we all are. I ended up emailing BK about it and explained that I am confused and asked if he could go over it again with me. I hope I hear back soon!

Valium.....Ahhhh

Ok, what the heck was I thinking for the past 4 MRIs....MRIs with Valium are the equivalent of getting a massage...and having your insurance foot the bill!! I have never actually enjoyed an MRI...until today. I was sorry it was over because I was so relaxed and happy. It flew by! I didn't want to get up when it was done! I could kick myself for not having requested it the other times...Oh well, live and learn!!!

Got Confirmation Yesterday

I got a letter saying that UHC has received my appeal and do I or anyone else want to add something. This gives me the perfect opportunity to send the new policy over to them. Anyone else have anything to add??? I know we all have something we want to say to them but I think I should watch my language in these letters!!

How Akward Is This

Yesterday, my good friend C called and told me that she had hurt her back, and was wondering if I could help her, and if I wanted to go to Target. Of course I said yes (to both). Around 7:00 she called to see if I was ready to go, I was, just had to change...until I went to pick something off of the floor and boom- my hip subluxed and totally threw my a curve ball. It hasn't subluxed "that much" since I have been more aware of the problem. I have been really careful and usually, once I feel the tiniest amount of sliding, I somehow manage to guard and not allow ti to sublux. Last night I couldn't. Within minutes, I was in a ton of pain. I called C back and had to explain why I could no longer fix her back or go to Target: "Ummm...I need to re-schedule, my hip kinda dislocated and it hurts a lot now...can you do tomorrow?" I think I should start taking my MRI Valium NOW!

Instability Is The New "Black"...

...Or at least the new "mystery" diagnosis that is being studied, kind of like FAI used to be, according to my OS. So once again, I am just a mystery...he has never seen anyone quite like me before. I am going to get an MRI hopefully this week and hopefully he can get an idea of what is going on. I am getting Valium for this one!!!

UHC- Revised Policy- Great News For Hipsters!!!

Surgical treatment, both arthroscopic and open, for femoroacetabular impingement (FAI)syndrome is proven*.

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

Great news for all of us with UHC!! Thank you to everyone who wrote letters, appeals, made phone calls and was interviewed. What an accomplishment!

In An Unrelated Story...

This week marked the 3 year anniversary of my left hip arthroscopy. Things have been great with Left, one surgery for a labral tear, cam and pincer FAI, 12 weeks of PT and done!!! Right hip....take a lesson!!

And The Nightmare Continues...

I got a response to the email I sent to my OS. He was at a meeting with my PT and they were discussing my unfortunate turn of events. He first wants me to get an MRI...this will be my 5th MRI in 3 years...did I mention I am claustrophobic??
All I keep thinking is that this is not going the way I had hoped...at 14 weeks post op, I am not supposed to be having MRI's, or depressing email conversations with my OS...what went wrong???? Why is this happenning????

Article on Capsular Laxity

Thank you to the generous people at JBJS for providing free articles to patients. I have a full copy saved on my desktop, if you would like it, email me suzq613@aol.com

Anterior Dislocation of the Hip After Arthroscopy in a Patient with Capsular Laxity of the Hip
A Case Report
Anil S. Ranawat, MD1, Michael McClincy, BA2 and Jon K. Sekiya, MD3
1 Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address: ranawatanil@hss.edu
2 University of Pittsburgh School of Medicine, 567 South Negley Avenue, Pittsburgh, PA 15232
3 Department of Orthopaedic Surgery, MedSport – University of Michigan, 24 Frank Lloyd Wright Drive, P.O. Box 0391, Ann Arbor, MI 48106. E-mail address: sekiya@umich.edu


Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania

The first 150 words of the full text of this article appear below.



Introduction

Capsular laxity is a poorly understood but increasingly recognized cause of hip pain1,2. As with shoulder instability, hip instability represents a wide spectrum of pathologic entities, ranging from acute traumatic dislocation to chronic capsular laxity. Primary capsular laxity is often associated with underlying collagen abnormalities, such as those seen with Ehlers-Danlos or Marfan syndrome. Secondary capsular laxity is seen more commonly in athletes and is secondary to overuse or repetitive activities2.

Although the mainstay of treatment for these conditions has been nonoperative, surgical intervention may be indicated because of either recurrent instability or lack of pain relief with nonoperative measures. Surgical treatment may require access to both the hip capsule and the labrum through either an open3-5 or an arthroscopic6-12 approach. Although the latter techniques are relatively new, two studies have demonstrated that arthroscopic surgery can provide stability to the hip joint10,11. However, while arthroscopic techniques are . . .

UHC Contacts

As I sit, wondering what will be with my appeal, I came across this website with some UHC contacts with email addresses. Since so many of you are finding my blog by googling terms like "UHC FAI" or similar things, especially in regards to denials, I thought this may be helpful.
IN the event that you do need to use these, keep in mind that it wasn't until I sent 2 emails to their VP of PR that someone responded to me.


http://consumerist.com/2008/03/email-addresses-for-united-health-care-executives.html
Read the comments, I found them interesting!

My Appeal Letter To UHC To Cover My FAI Surgery

TO: UnitedHealthcare Appeals Department

DATE: February 29, 2010

FROM: Name
Member #
Claim #:

RE: Appeal Letter Regarding Arthroscopic Hip Surgery



Mailed to _______________________




Dear Sir/Madam:

This letter serves as an appeal to the UHC denial of the arthroscopic hip surgery performed by Dr. ____on 11/30/2009. This surgery was performed to debride a torn acetabular labrum as well as to correct my femoroacetabular impingement (FAI) syndrome. United Healthcare’s rationale is that arthroscopic surgery for FAI is unproven; this was documented in a letter dated 12/30/09 from Bradley J. Osborne, MD, Medical Director. This letter states that these services are “experimental or investigational”.

United Healthcare’s decision should be reversed for three reasons. First, I have undergone this procedure by the same in-network physician in the past, and it has been covered by UHC (3/5/07, 7/2/07 and 11/12/07). Second, my medical history demonstrates that a surgical alternative was necessary and appropriate. Third, the medical literature and coverage by other major insurers supports the use of arthroscopic surgery for FAI, therefore, it would appear to the reasonable person that UHC is discriminatory in their policies.

I. This Procedure Has Been Covered In The Past

I have undergone this procedure 3 different times in the past, the first one was performed on March 5, 2007, the second was performed on July 2, 2007 and the third was performed on November 12, 2007. These procedures were covered at the negotiated rate with UHC, as Dr ____ is an in-network provider. I was never notified by UHC that this procedure would not be covered. Obviously, my concern is the reliability of UHC. There must be consistency of processes in order to avoid costly mistakes like this


II. My Medical History Supports A Surgical Response

Femoroacetabular impingement (FAI) occurs when the ball (head of the femur) does not have its full range of motion within the socket. It 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. Impingement causes pain, decreased range of motion and mechanical symptoms such as locking of the joint.

I relentlessly attempted to manage my FAI with conservative measures, including strengthening of the hip muscles, activity modification and several injections into my hip; however, my pain became debilitating and my range of motion became quite limited. As a young, active, and very healthy 29 year old, and only after conservative treatment failed, I decided it was best to pursue surgical treatment because chronic pain and immobility can lead to risk for multiple health conditions, such as obesity, depression, diabetes not to mention the very realistic probability of needing a premature total hip replacement.

My doctor, Dr.____– a world renowned expert in arthroscopic hip surgery –explained that I had exhausted all of my conservative options and in order to relieve my symptoms, he recommended arthroscopic hip surgery because it involves minimal complications, minimal pain, very low risk of infection, and a short recovery time, all on an outpatient basis. There are other treatment options that include open surgical dislocation as well as a total hip arthroplasty, but unlike arthroscopic treatment, these require that the hip be dislocated which increases the risk of avascular necrosis. As you are aware, avascular necrosis by itself is a complication that can contribute to serious morbidity. Thus, the risks and the potential costs to United Healthcare and the patient, are lower with the arthroscopic procedure. This is also confirmed by the Hayes report as the clinical options. Additionally, at my current age, activity level, and amount of cartilage wear, I do not qualify for a total hip replacement.


Please note that I am well on my way to an excellent outcome thanks to Dr.____’s ability to provide me the state-of-the-art treatment that has been developed and tested, as evidenced by scholarly publications and as an approved surgery by Blue Cross, Kaiser, Blue Shield, Cigna and other insurance companies. This surgery has improved my quality of life and ability to function, which will allow me to avoid premature total hip arthroplasty and the medical treatments associated with chronic disease.



III. The Medical Literature Supports this Procedure for FAI

As indicated in the outset of this document, United Healthcare has denied coverage because this procedure is “unproven.”

United Healthcare’s definition of “unproven services” is as follows:

“Services that are not consistent with conclusions of prevailing medical research which demonstrates that the health service has a beneficial effect on health outcomes and that are not based on trials that meet either of the following designs.
-Well conducted randomized controlled trials
-Well conducted cohort studies
Decisions about whether to cover new technologies, procedures and treatments will be consistent with conclusions of prevailing medical research, based on well-conducted randomized trials or cohort studies, as described.”

A review of the “prevailing published peer-reviewed literature” shows that arthroscopic surgery is not “unproven” for FAI.

In regards to my condition and the treatment Dr. ___provided, UHC should fully understand that FAI is a condition that is painful and debilitating as was my experience as well as countless others. As Dr. Osborne, the original UHC denying doctor, is a general surgeon he may not know the extent of the disability associated with FAI. It is a condition that has been recognized in the literature since the 1930’s (Smith & Peterson, 1936). Femoroacetabular impingement syndrome is the result of abnormal contact between the proximal femur and acetabulum and can result in intra-articular pathology and eventual osteoarthritis (Beck et al., 2004; Ganz et al., 2003).

Furthermore, FAI is one of the most common causes of premature osteoarthritis in men and women (e.g., Ganz et al.., 2003; Murray & Duncan, 1971; Smith & Peterson, 1936).

Although the open hip procedure has historically been the “gold standard,” perhaps due to previous technological limitations, there are extensive complications, chronic disability and pain associated with it as well. Additionally, UHC has recently taken the position to not cover open FAI surgery. Again, UHC is being discriminatory in their coverage for FAI. UHC has refused to pay for ANY required surgical repair of this syndrome.

Bedi et al. (2008) published a systematic review of the surgical treatment of FAI syndrome. These authors report that there are only five scholarly articles (peer reviewed journals) published reporting outcomes of the open surgical approach with 20 or more hips included. Good outcomes achieved ranged from 65-85% of hips (Beck et al., 2004; Beaulé et al., 2007; Espinosa et al., 2006; Murphy et al., 2004; Peters & Erickson, 2004).

There are more outcome studies published in peer-reviewed journals on the arthroscopic correction of FAI syndrome and/or other intra-articular pathology that include 20 or more hips, which is a stronger compilation of evidence than for that of the open procedure (Byrd & Jones, 2000; Farjo et al., 1999; Ilizaliturri et al., 2008; Larson & Giveans; O’Leary et al., 2001; Philippon et al, 2007; Potter et al., 2005; Santori & Villar, 2000).

Of high importance, the success rates of the arthroscopic procedure were achieved without the complications, such as avascular necrosis, associated with the open hip dislocation. In fact, the Hayes report indicates that there is a 1.3% complication rate with the arthroscopic procedure compared to a “10-12%” complication rate of the open hip surgery. Additionally, more recent studies not included in the Bedi et al. article, support evidence for long-term benefits (Ilizaliturri et al., 2008; Philippon et al., 2009).

Although the Hayes report provided a superficial analysis of the evidence for United Healthcare, there is one thing in the Hayes report that clearly stood out: arthroscopic FAI surgery must be performed by an orthopedist with special training in hip arthroscopy. Not only does Dr. ___have special training, he is an international leading expert in arthroscopic hip surgery, which is partially reflected by prestigious publications in multiple peer reviewed journals.

United Healthcare seems to believe that arthroscopy is unproven because studies only cover a two-year period as indicated in “Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up.” Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23. My question for United Healthcare is would four years be enough? Ten years? This seems like nothing more than a convenient excuse to avoid coverage of a procedure that has proven to be safe and effective.

In a more recent article published by Byrd and Jones, “Prospective Analysis of Hip Arthroscopy with 10-year Followup”, response to hip arthroscopy was investigated in a consecutive series of patients with 10 years followup. All patients undergoing hip arthroscopy were assessed prospectively with a modified Harris hip score preoperatively and then postoperatively at 3, 12, 24, 60, and 120 months. The median improvement was 25 points (preoperative, 56 points; postoperative, 81 points). This study substantiates the long-term effectiveness of arthroscopy in the hip as treatment for various disorders, including labral pathology, chondral damage, synovitis, and loose bodies.

There are many published studies indicating the effective results of arthroscopic treatment of FAI. The largest study to date is Sampson, T.G. (2006) “Arthroscopic treatment of femoraoacetabular impingement; a proposed technique with clinical experience.” In this study of 183 hips, 94% achieved a high degree of satisfaction with the surgical outcome. Only six patients had subsequent total hip arthroplasties. The results further showed that for the majority of patients’ pain decreased by 50% in 2 to 6 weeks, 75% by 5 months, and 95% by 1 year. In addition, there has recently been a publication in the British Journal of Bone and Joint Surgery by Dr. Marc Philippon. He is an authority on the subject and has published extensively on the topic, as you should be aware. In this article he documents the improvement provided to a group of patients undergoing the arthroscopic procedure with over two years of follow-up. The reference for the article is: “Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up.” Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23.


Again, United Healthcare relied on a Hayes report that UHC says was updated based on studies from 2007 and 2008. However, the key study by Philippon from 2009 was not utilized in UHC’s “science” based determination of my claim. Additionally, the small print in the Hayes report indicates that this report “is not intended to be used as the sole basis for determining coverage, reimbursement or technology acquisition” (Hayes report). There was no indication that my clinical information or communication initiated by UHC with my physician was taken into account.

United Healthcare claims that there may be (not are) problems in the long term. United Healthcare can cite no study showing that there are problems in the long term. In fact, there is no evidence of this, and what we do know is that this procedure avoids avascular necrosis, the risk of which is inherent in an open procedure. So what has to be balanced is the risk of avascular necrosis and other serious complications against the entirely speculative possibility of long-term problems with arthroscopic surgery. In other words, we are balancing a known complication against an unknown, entirely speculative one.

The circumstances in which this surgery was performed, and the literature pertaining to this surgery, have not yet been reviewed by an orthopedist. United Healthcare’s reviews have been by a general surgeon. I strongly believe that, if a proper review was conducted, the finding would be that this procedure ought to be covered as it is covered by Kaiser, Blue Cross, Blue Shield, Cigna and others.

In conclusion, it appears that UHC needs to catch up with the evidence, and reverse their policy of viewing arthroscopic, as well as open treatment of FAI as unproven. Not only is this false, as evidenced above, it is discriminatory to those afflicted with the condition. Specifically, denying the procedure to patients is clinically wrong and misguided. There is clear literature to support the lasting improvement afforded by this operation. More importantly, not performing the procedure and letting patients wait until they are in enough pain or have enough deformity to warrant a total hip replacement keeps patients in pain and suffering for an inordinate amount of time. There is a procedure that can help patients and improve their quality of life with a minimum of surgical trauma, yet you choose to disallow it, based on a superficial analysis of the available clinical series.

IV. Conclusion

Despite my good physical recovery, I have been unnecessarily stressed by the lack of a fair and consistent policy UHC has demonstrated since my claim was filed. Be assured that I intend to use every available means to get this matter resolved as I’m interpreting UHC’s actions to be discriminatory. In the meantime, I will await a thorough and scientific review of my appeal by an orthopedic specialist apprised of the current knowledge base surrounding FAI. I am expecting payment on my claim as I believe the literature does support that this procedure is not unproven. This is also evidenced by multiple other insurers covering this procedure.

Please do not hesitate to contact me with any specific questions or if additional information is needed.

Sincerely,

Susie








Additional References

Prospective Analysis of Hip Arthroscopy with 10-year Followup. Byrd JW, Jones KS. Clinical Orthopaedics and Related Research

Sports and Recreation Activity of Patients With Femoroacetabular Impingement Before and After Arthroscopic Osteoplasty. Brunner A, Horisberger M, Herzog RF.
Am J Sports Med. 2009 Feb 26. [Epub ahead of print]

How accurately can the acetabular rim be trimmed in hip arthroscopy for pincer-type femoral acetabular impingement: a cadaveric investigation. Zumstein M, Hahn F, Sukthankar A, Sussmann PS, Dora C.
Arthroscopy. 2009 Feb;25(2):164-8.

Arthroscopically assisted anterior decompression for femoroacetabular impingement: technique and early clinical results.Hartmann A, Günther KP. Arch Orthop Trauma Surg. 2009 Jan 6. [Epub ahead of print]

Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Byrd JW, Jones KS. Clin Orthop Relat Res. 2009 Mar;467(3):739-46.

Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23.

Femoroacetabular impingement treatment using arthroscopy and anterior approach.
Laude F, Sariali E, Nogier A. Clin Orthop Relat Res. 2009 Mar;467(3):747-52.

Arthroscopic management of femoroacetabular impingement: early outcomes measures.
Larson CM, Giveans MR. Arthroscopy. 2008 May;24(5):540-6.

Complications of arthroscopic femoroacetabular impingement treatment: a review.
Ilizaliturri VM Jr. Clin Orthop Relat Res. 2009 Mar;467(3):760-8.

Arthroscopic treatment of cam-type femoroacetabular impingement: preliminary report at 2 years minimum follow-up.Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-Rodríguez E, Camacho-Galindo J. J Arthroplasty. 2008 Feb;23(2):226-34.

Arthroscopic treatment of femoroacetabular impingement secondary to paediatric hip disorders. Ilizaliturri VM Jr, Nossa-Barrera JM, Acosta-Rodriguez E, Camacho-Galindo J. J Bone Joint Surg Br. 2007 Aug;89(8):1025-30.


Early outcome of hip arthroscopy for femoroacetabular impingement: the role of femoral osteoplasty in symptomatic improvement. Bardakos NV, Vasconcelos JC, Villar RN.
J Bone Joint Surg Br. 2008 Dec;90(12):1570-5.

Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.

Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults. Peters CL, Erickson JA. J Bone Joint Surg Am. 2006 Aug;88(8):1735-41.

Arthroscopic offset restoration in femoroacetabular cam impingement: accuracy and early clinical outcome. Stähelin L, Stähelin T, Jolles BM, Herzog RF.
Arthroscopy. 2008 Jan;24(1):51-57.

Influence of femoroacetabular impingement on results of hip arthroscopy in patients with early osteoarthritis. Kim KC, Hwang DS, Lee CH, Kwon ST.
Clin Orthop Relat Res. 2007 Mar;456:128-32.

Quality of life following femoral head-neck osteochondroplasty for femoroacetabular impingement. Beaulé PE, Le Duff MJ, Zaragoza E.
J Bone Joint Surg Am. 2007 Apr;89(4):773-9.

Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Philippon M, Schenker M, Briggs K, Kuppersmith D.
Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14.

Debridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Murphy S, Tannast M, Kim YJ, Buly R, Millis MB.
Clin Orthop Relat Res. 2004 Dec;(429):178-81.

Hip damage occurs at the zone of femoroacetabular impingement.
Tannast M, Goricki D, Beck M, Murphy SB, Siebenrock KA. Clin Orthop Relat Res. 2008 Feb;466(2):273-80.

Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Clin Orthop Relat Res. 2004 Jan;(418):67-73.

Revision hip arthroscopy. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ. Am J Sports Med. 2007 Nov;35(11):1918-21.

































Attachment 1


Examples of Other Insurance Carriers Policy on FAI Including:

Cigna

BlueCross BlueShield of North Carolina

BlueCross BlueShield of Mississippi

Regence

Anthem

(I printed out the above companies policies and included them)
BCBS N. Carolina: http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/arthroscopic_surgery_for_femoroacetabular_impingement.pdf
BCBS Mississipi:
http://www.bcbsms.com/index.php?q=provider-medical-policy-search.html&action=viewPolicy&path=/policy/emed/Surgical%20Treatment%20of%20Femoroacetabular%20Impingement.html
Cigna:
http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0485_hip_arthroscopy_for_femoroacetabular_impingement_syndrome.pdf
Anthem Blue Cross
http://www.anthem.com/medicalpolicies/policies/mp_pw_b099013.htm
Kaiser demonstrates their surgery for FAI:
http://xnet.kp.org/misg/procedures/orthopedic.html
Regence covers it as well.



Attachment 2

Copy of an external review for another UHC member who was denied coverage for an almost identical procedure. Please note that this reviewer, an orthopaedic specialist, stated that this procedure should not be considered investigational or experimental at this time. Additionally, this external reviewer indicated that UHC was arbitrary and unethical in their decision to deny this claim.

Good News and Bad News

This is what I told J I had for him when I left PT today. He wanted to hear the bad news first.

Bad News: my hip is pretty f--ked up. My PT has never seen anyone with my issue, meaning someone who has so much instability following a capsule repair. He is not really sure what to do but is not giving up. In the meantime, he gave me one simple exercise to do at home. I see BK in 2 1/2 weeks so until then, this is it. My pain has been excruciating at times. Yesterday I had a 2 hour meeting and thought I was going to die when I left. This is just like pre-op, when I go to work I have pain. I am going to email BK tonight to see if he has any thoughts.

Good News: I had no co-pay at PT because he felt so bad for me!

More UHC.....

As I have noted in the past, UHC has denied payment for my last surgery. It has been resubmitted numerous times and still denied. After Maria's article was published, I contacted Cheryl Randolph, the PR exec from UHC quoted in the article via email, regarding my claim. I cc'd a few other PR people at UHC as well. I got no response. I sent another email to the same group of people this week, but signed it with my credentials (thanks Maria!). When I got home from work today I had a message from Linda @ UHC regarding my emails.

I called the number and got UHC corporate offices...ooh lala! Linda is a consumer advocate, she told me I would need to appeal the decision. What I explained was that I didn't see the need to do this since the procedure had already been paid for 3 previous times. She was stumped. Regardless, she said to write an appeal and send it to her, and she would expedite it and get it to the right people. And to make sure I stated that it had been previosuly paid for.

I don't know if in the end this will help me or not, but it pays to be the squeaky wheel...someone is going to listen...or get really annoyed!

FML

That pretty much describes the way I am feeling right now. I am having a lot of discomfort in my joint, and have felt my hip "shift" or "sublux" or "de-stabilize" or something multiple times. I am not a happy camper to say the least. I had PT today and my therapist is very concerned about this. He thinks that my femoral head is sitting anterior, which is why I don't have full hip flexion, and why I am so unstable. It is anterior because I have nothing restraining it, I ruptured the ligamentum teres on that 'fateful' June night, and he is pretty sure that my capsular shift was ineffective. He thinks that most likely my capsular tissue was no longer of good quality and just couldn't hold the repair.

That leaves me beyond upset, angry, sad, disappointed.....3 fucking surgeries later and I still have pain. He told me not to give up yet....he is not giving up yet. At this time I am really inflamed so I can't do much of anything. He was also palpating around my ASIS/AIIS and found swelling...he is not sure why but thinks that something there is also very inflamed and irritated. Fabulous.

I am to do one exercise for now. Lying on my back with my knees bent, push my hands into my knees and hold for about 10 seconds. This is to activate my abs...which have most definitely shut down. I iced with the gameready afterwards...it felt great. He wants me to rent one for now but I know I won't use it! It is bags of frozen vegetables for me!!!

He also thinks it may be helpful to get an active fluoroscopy of me bending forward to see exactly what is happening in the joint, and to get an idea of how 'fixable' I am!

Back To Work!

Well, the party had to end at some point I guess, and it was back to work for me yesterday! Work itself went well, it was extremely busy and I had a ton of paperwork, but I managed! Yesterday morning I had what I have come to call one of my "episodes", where I will be doing something and my hip feels like it is subluxing. It usually happens when I am bending down to get something from the floor. It really hurts and is really disconcerting, especially after having surgery to stabilize my hip. I had on and off pain throughout the day, at periods I had no pain at all and others I had excruciating pain. Today was the same, on and off pain throughout the day.I am extremely frustrated with this and was hoping that by 3 months I would be past this. Tomorrow I have PT so hopefully we can work on stabilizing me a little bit and avoid this.

Good News For One Reader

Whenever someone posts a comment on my blog, I get an email about it, even if it is an old post. I was thrilled to get this comment today from Tim on the post about UHC's new FAI ruling:

"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"

Congratulations Tim!!! I hope to get more news like this very soon from many readers!!!

Overcoverage, Undercoverage...Why Can't I Just Get It Right!

I have been totally slacking on the blogging front and once again apologize. I just feel the need to be done with hip shit once and for all.
I am totally done with my original PT and now on to PT #2, who works closely with my OS.

I have been having some feelings of instability, especially when I bend down quickly. Also, I went sledding on Sunday and walking up the hill killed me the next day. I had a lot of groin pain and got really nervous.

I told PT #2 that I really want my full hip flexion, on top of the other things that are going on. He said that one of the issues is that my capsular shift is not doing what its supposed to do, and my hip feels "sloppy", when he externally rotates it there is almost no end feel, it just flops. He also felt that my femoral head was too anterior causing it to jam up into the joint, so he wants to try some things to reposition it. He ended up taping me into a little pelvic anterior rotation to try to get more coverage of the femoral head. After a few hours I had a lot of back pain so had to remove it. We are going to work on some exercises from now on to get that back into place.

He also worked on some muscles trying to get my hip flexion increased. There is a spot on the inside of my leg where the adductor meet the VMO that is incredibly tender, he worked it so hard but it increased my ROM...not without leaving behind some nasty marks though!

I go back to work on Monday...I am nervous about it...I will keep you posted!

Take That UHC

Many many thanks to fellow hipster Maria, who is paving the way for the rest of us to have our claims paid. Below is an article she was interviewed for in the New York Times. As you can see, the article quotes Cheryl Radolph, VP of PR at UHC, who says "the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure"

Funny, because my surgery was not covered, and the reason UHC gave me is that "This Service Is Unproven And Is Not Covered. Therefore, No Benefits Are Payable For This Expense. In Order For This Service To Be Considered For Coverage, Scientific Evidence Must Be Submitted, That Meets The Standards Described In Your Benefit Plan Language, That Demonstrates The Safety And Effectiveness Of This Service For Your Particular Condition".


Fighting Denied Claims Requires Perseverance

MARIA CARR, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.

Her doctor told Ms. Carr he had successfully performed this procedure for eight other UnitedHealth patients suffering from the same ailment in the same year. To Ms. Carr’s mind, arthroscopy seemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.

“When the denial came I was shocked,” Ms. Carr said, “but I figured I’d just have to find a way to pay.” The total bill for the hospital and surgeon fee was $21,225.

Ms. Carr’s form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.

Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.

But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a local charter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.

“I decided I would fight,” she said. “After all, what did I have to lose?”

Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.

The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer’s external review board, where an impartial medical expert weighed the evidence.

The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. “The expert felt UnitedHealth couldn’t call the procedure experimental if it paid for other patients to have it,” Ms. Carr said.

UnitedHealth ended up paying $12,282 for Ms. Carr’s claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr’s share was about $500.

“That’s what the appeals process is there for,” said Cheryl Randolph, a spokeswoman for the insurer. “We’re glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to.”

Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr’s successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure.

Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor’s use of the wrong diagnostic or treatment code for your treatment.

Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr’s case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement. Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.

Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar with insurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.

But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.

“About 53 percent of appeals work in our state,” said the Kansas insurance commissioner, Sandy Praeger. “That demonstrates that the process works.”

Use the following advice to increase your chances of success in appealing a health insurance denial. As you’ll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.

READ YOUR POLICY Always check your policy carefully before you undergo treatment.

Many denials are made because the policy specifically excludes coverage of a certain treatment, procedure or medicine, Ms. Praeger said. When it is spelled out that something specific is not covered, an appeal will not work.

TAKE YOUR TIME When you decide to appeal, do not act in haste, advises Ms. Jaff, of the patient advocacy group.

Most insurers allow a certain amount of time to file for an appeal, usually 60, 90 or 180 days. If you call and say I want to appeal, an insurer may consider that the appeal itself. So you want to take advantage of the time you have (without missing the deadline) to build your case.

Before you file, make sure you have all the information you need from your insurer to start your appeal in earnest. Your explanation of benefits should provide a code for the reason for the denial, and that code should be translated somewhere on the statement. If it is not or if you still have questions, contact your insurer.

Make it clear in your phone call or letter that you are not officially starting the appeal process. You simply have questions. If it is not already clear, you should also ask exactly to whom the appeal should be sent. (You do not want precious time wasted because your appeal was shuffled from desk to desk. )

Whenever you call your insurer, be sure to make a note of the time and date and the person you talked to. If you send a letter, send it registered mail with return receipt, and keep your own copy.

DO RESEARCH Once you learn why your claim was denied, customize your appeal to argue specifically against that reason. A clerical or coding error is fairly straightforward, but just to be sure, enlist the help of your doctor’s or hospital’s billing specialist to back you up with a letter explaining how the mistake was made.

Something more complicated, like an out-of-network emergency claim, will require proof that the situation was indeed a medical emergency and that no in-network provider was available. Obtaining your medical records can help support your argument, so can letters from the doctors who treated you.

Fighting a denial for something your insurer deems experimental can be the trickiest appeal. In addition to support from your doctor, you will need to find articles from established medical journals for evidence that the treatment is not only effective but safe.

You can find abstracts of many articles free on pubmed.gov, the library of the National Institutes of Health. Often the abstracts are enough to make your point. If you need the full article, which can be expensive, ask your doctor’s office for help or check with a local medical school library.

Any proof you can show that other insurers in your area cover the treatments in question can be valuable. Most big insurers list medical policies concerning treatments on their Web sites. Your doctor’s office can probably help with this, too.

You also must prove the medical necessity of a treatment, especially if it is considered experimental.

Ms. Jaff, for instance, learned this when she was denied coverage for a certain drug her doctor prescribed for Crohn’s disease. Her insurer argued that other, more established drugs could treat the problem. True enough, but Ms. Jaff had already tried those drugs without success.

For her appeal, Ms. Jaff collected her medical records that showed when she had tried each drug and how each had failed. The strategy worked, and her claim was ultimately paid.

Be sure to stick to the facts in any argument you make. Emotional or angry arguments, as much as they may feel warranted, will not help your case, said Erin Moaratty, who heads special projects for a group called the Patient Advocate Foundation.

GO THE DISTANCE Even if your well-researched and thorough appeal is denied, do not give up. You still have options, depending on the type of insurance you have.

If you receive coverage directly from an insurance company, say through a private policy or from your small or midsize employer, your insurer is regulated by your state’s insurance department. All but five states, Alabama, Mississippi, Nebraska, South Dakota and Wyoming, allow patients to have their appeals considered by an independent external review board, usually after all internal appeals have been exhausted.

In most cases the board consists of doctors and other professionals with an expertise in your condition. For more information on your state’s rules contact its department of insurance. To find yours, go to the National Insurance Commission’s Web site and click on your state.

Large employers that self-insure — meaning that they pay medical claims themselves, not through an insurance company — are not subject to state insurance laws. But most have provisions for external appeal reviews. Check your plan summary, the large booklet you received when you signed up for health care, for details.

GET HELP Your state insurance department can help answer questions and start an appeal. In addition, groups such as Advocacy for Patients with Chronic Illness and the Patient Advocate Foundation help seriously ill patients file appeals free.

Be sure to check the advocacy organizations for the illness you have. Many offer free advice on dealing with health insurance disputes with specific information related to your condition.

You may also want to seek help from a medical billing advocate (see our earlier column “A Guide through the Medical Wilderness”). Depending on the case, these professionals charge an hourly fee or a percentage of any recovered claim.