Original PDF TRICARE Manual Here
4.10 Hip resurfacing (CPT2 procedure codes 27125 and 27130, and HCPCS S2118) with an FDA approved device is proven for the treatment of Degenerative Joint Disease (DJD) of the hip in patients who are less than 65 years old and who meet all of the following criteria:
| John WilliamsonJanuary 17, 2006 Harvard Pilgrim Health Care 1600 Crown Colony Drive Quincy MA 02169-9777Re: Appeal of denied coverage, HP0412161-00Dear HPHC Representative:I am requesting for voluntary member reconsideration. Following is an explanation of my medical condition and history. In a letter dated December 23, 2005, HPHP denied my requested authorization for a total hip resurfacing.My Condition and HistoryI have DX with degenerative arthritis of the left hip, which restricted |
| November 9, 2007HMO Help Center Department of Managed Health Care 980 9th Street Sacramento, CA 95814-2725This cover letter accompanies my application for an Independent Medical Review (IMR). The core issue in this case is hip resurfacing (HR) versus total hip replacement (THR). In this letter I will discuss some of the main issues relevant to my case. In a second letter I will address some issues regarding the qualifications of IMR reviewers.My |
THE APPEAL LETTER TO CIGNA (NAU IS “national appeals unit”)
Dear CIGNA NAU:
I have received your written notice, dated Aug. 27, 2004, denying my initial
request for pre-authorization for left hip surface arthroplasty. With this
letter and attachments, the request is being re-submitted for further
consideration as an appeal of the initial denial.
I am a 55-year-old male diagnosed in March of this year with end-stage
osteoarthritis of the left hip, with “some … Read the rest
Dr. De Smet 2006 |
Insurance Appeals 101For those of you who have not had experience with insurance appeals, here’s a couple of tips I learned helping patient families with insurance appeals:(1)First and foremost, read your policy – the full document with all of the legalese, not just the coverage pages. Your employer should have a copy of the policy or coverage book or you can usually get it directly from the insurance company. |
| “I was able to return to my pre-surgery climbing level after six months, and was quite active in the second half of 2005 with climbing and hiking.” |
| Friday, January 13, 2006Success with U.S. Insurance (LONG) Eleven months after surgery in Belgium, I finally obtained insurance reimbursement for 100% of my medical expenses. Here are details. My health insurance is an ERISA plan. This means that my employer is self- insured, but hires a health insurance |