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!