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.
21 comments:
Looks good, you've covered the key points. One additional note, a key term people may want to use throughout their appeals letter is "MEDICALLY NECESSARY". In the beginning of the letter it is important for the patient to spend time describing, IN DETAIL, how this condition effects their life daily to support WHY this procedure was "Medically Necessary". Don't be afraid to give specific examples to paint the picture for them. For example, issues with your children, taking care of yourself, work. This information is important because it helps further support WHY your surgery was MEDICALLY NECESSARY.
Also, it is helpful to include ANY/ALL of the treating surgeon's credentials/hospital's reputation to support any claim that the surgeon/facility is an "expert", otherwise, the reviewer can choose to discount it as simply your opinion(not all, but some will). Let's just say you know the reviewer is not going to go looking for your surgeon's credentials! Again, make sure to state that the surgeon determined the need for your surgery to be "Medically Necessary" & include a letter from the surgeon's office if you have one. Typically, the patient has an appeals process & the provider has an appeals process (provider generally has 2 levels of appeal). The two are SEPARATE appeal processes & can happen at the same time. One doesn't count towards the other! This is important to know because many times a patient will call the biller when they receive a denial & the biller will give them incorrect info by stating "You don't have to do anything-we're appealing it." You can wait, but it is in your best interest to start the appeals process. The person in the surgeon's office who generally handles the appeal is the biller. Some billers do a great job with their appeal & you can ask them for a copy of their appeal letter as well as any articles they used to support the claim. Unfortunately, other billers don't go out of their way & don't have any info to give you. Some are simply clueless with regard to what a good appeal looks like!
One last note, be careful not to beat up the "open" procedure too much because in some cases, you may end up needing to go the open approach later (hopefully not, but it does happen) & you don't want to give them amunition. Not to mention, the policies are against BOTH arthroscopic AND open procedures for FAI, so there really is no need to go down that road!
The good news is, it seems that for the most part, the insurance companies are paying for this procedure if people simply take the time to write the appeal & hold their ground. When the appeal finally gets in the appropriate reviewers hands (OS), it gets approved.
I'll be suprised if your appeal doesn't get overturned at this point! Great job!
Wow! Great points! Thank you!! If this gets denied I will add all of that to my second level appeal!!!
In my situation, UHC counted a letter I sent to them in which I specifically stated, "This is not an appeal" as an appeal. I was was requesting their scientific rationale for my initial denial as all insureds are allowed that information. UHC counted my 2nd appeal as the "redetermination" request my doctor's office had sent. UHC also told me that my two appeals could be used up by either myself or my physician. Of course, UHC indicated this after the fact. That is how I ended up pretty quickly at external review.
I would urge patients to also cite any types of denial of due process in their appeals.
Maria,
I just advised another patient about this "tactic". Regence is trying to tell the patient that they need to go over a "form" with them on the phone & then they will fax them the rest to "fill out". I told this patient to tell the insurance company to fax the form and do not give any info verbally. Period. In addition, they need to be aware that the form may be written in a way that limits space to provide info or has boxes to check in attempt to give the insurance co. an advantage. The patient will need to fill the form out strategically and make sure that a letter & supporting material go with the form.
Insurance companies will also tell you that you just need to call and verbally request an appeal. NEVER EVER DO THIS! Obviously this means there is no letter, no facts sent to a reviewer and it is easy to uphold the denial & exhaust one of your appeals.
Before doing ANY appeal, make sure you get a copy of your policy's appeal process in writing. Maria, I would double check on the claim that the provider's appeal counted toward your appeal process...that should not be the case unless your employer set up the plan that way(would be unusual).
Your right about including ALL & ANY info pertaining to how the insurance company broke the policy re: your appeal process, including if an appropriate specialist didn't review your claim. You should always receive a claim denial letter w/the reason (usually no scientific evidence included, you can look up the "medical policy/bulletin" pertaining to your surgery & that will list the articles they are using to support that it is investigational) for the denial & who reviewed the case.
Ask for a supervisor. Don't waste your time w/a customer service rep.
Good luck!
I already won my external review. I also had filed a complaint about the Dept. of Insurance and I had a justified complaint against UHC.
Yes, I argued all of your points. The first "specialist" that denied my hip scope claim through UHC was an urologist. I did point out to UHC that I understand that a urologist would be specializing in the same "geographic" region of the body as a hip specialist, but they should be aware that they are completely two different specialties.
UHC was just downright unethical.
Maria,
That's awesome! It just goes to show that if you keep going & don't let the insurance company tactics derail you, scare you, make you walk away, more often than not, YOU WILL WIN! Its great that you went the additional step to report them!
Wow! How can they ever deny cover for this surgery ever again after that letter lol
UHC is just plain unethical. I am currently on my second appeal to have my twin son's neonatology claims paid. I received a letter at the end of March from the appeals department stating I had won the appeal. A few days ago I received a "corrected letter" once again denying coverage. They had changed their mind. I am requesting a face to face interview with the review board.
Hi,
I am gathering materials for an appeal process to be covered for FAI. One thing that would help GREATLY is to have a letter or specific information for someone who has been covered by his/her health insurance for arthroscopic FAI treatment. Does anyone have Maria's contact information (from above)?
If you have been covered, or if someone whose contact information you have has been covered, PLEASE oh please contact me: td994018@gmail.com
Thanks,
Tim
Hey Susie (and all),
I have linked to this appeal letter from the Hip Preservation Portal's insurance info page, as I have begun updating and adding policy information in relation to femoroacetabular impingement and hip dysplasia (PAO) sugeries.
Susie, just wanted to let you know I have linked to you.
Everyone, if you have any policy information/statements you have found and would like to add, feel free to email me.
The more we get the word out there about SUCCESSFUL outcomes, certainly the more we can help others and change the course of direction of coverage since some insurance companies DO pay for such named procedures.
Namaste~
Super Hip Chick
Areyou now covered?
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 ... UHC has also reversed their original denial for my treatment. Surgery scheduled for June 10th!
--Tim
td994018@gmail.com
I am now covered!
Can anyone tell me how to get the articles referenced in this appeal? Are they on the internet? Also has anyone won an appeal with Regence Blue Shield?
Hi All,
I'm glad this has been helpful. I wrote this letter helping Maria. My surgery was covered no problems but I have a passion in advocating for others. I have written other versions of this letter. For many people it is much better to keep the letter much shorter. I'd be happy to help anyone get the articles. All of the articles are in the files on the FAI yahoo group.
Sun
Hi Susie
Can you please email me at smora1016@hotmail.com?
I dont want to say much on just a post but I need your help!
I am gathering information to your post good subject to explore. Will certainly visit your site more often now.
aljur
I am gathering information to your post good subject to explore. Will certainly visit your site more often now.
aljur
WR
I am glad I found this site, the info is helpful but I am up against some significant challenges. I have severe damage to my left hip. I have FAI, I believe all three types. Excuse my ignorance about all this, I am having to dive into something that was not my purview.
I am a former-Special Operations Soldier, my background is similar to a high-level athlete, with one key difference, I have sustained a lot of injuries due to my work, some due to significant events, others due to the lifestyle and requirements of the job, the physical training, the training in general, i.e. parachute operations, decades of combatives, etc... you get the drift. I was a very active athlete into my mid 20's, I have been a runner all my life, a power-lifter and all around activity junky.
I am no longer on active duty, I am a reservist with Tricare Reserve select insurance.
I just found out Tricare will not pay for Reservists to get ANY work done on my hip, not to correct the FAI nor to fix ANY damage associated with it, from it or related to FAI. I have extensive labral tearing, significant cartialiage damage, massive arthritis and bone spurs. Oh, by the way I am only 42 years old. I had to recently leave my job as a government contractor as I could no longer do the work, I am unemployed, can't work doing anything related to my skills, can't sit for any length of time, cant stand long periods. I have significant pain, my leg is numb often, pain not only in the hip but in my knee and lower back. That is how this was first diagnosed, I thought I messed my knee up, upon examination the ortho discovered the hip issue.
Tricare pays for all of this but only for Active Duty Soldiers not for Reservists, the insurance is the exact same, I can go out of network, etc...I only got one surgeons office to talk to me after finding out I have Tricare, many won't even return my calls once they find out my insurance.
I don't have 15-20K to get this done, if I don't I have zero quality of life, I can't work, I can't get disability my claim was denied, which I am appealing and debating a worker's comp suit against my former employer. It is a tough injury as I can't pinpoint when exactly it was done, it was a slow progression into the debilitated state I am currently in.
Any help or suggestions would be greatly appreciated.
Thanks,
WR
WR- I am not all that familiar with tricare and it's rules. I do know some people have been denied arthroscopic surgery with tricare and had to have open surgery. Your particular situation sounds like a coverage issue specific to your plan. WC may be a way to go for you, or appealing for coverage in your situation. Good luck
HORIZON AUTHORIZED OUR PATIENT'S FAI SURGERY DONE ON 12/22/14 BUT TO DATE, WE HAVE NOT GOTTEN PAID. MY FEELING IS IF A PROCEDURE IS AUTHORIZED AND THE POLICY IS ACTIVE, THE PROCEDURE SHOULD BE REIMBURSED PLAIN AND SIMPLE. Good luck with your efforts. sheriaos@yahoo.com
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