Category Archives: Insurance Appeal

Appeal Submitted to my HMO by Dr Gross February 2020 for Danny’s Hip Resurfacing

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I thought this might help others trying to get insurance approval for out of state hip resurfacing. This was written by Dr. Gross on 20/29/2020.

Wording of Remote Consultation which was submitted to my Insurer by Dr Gross’ office.  This was the only attachment to an intake form for the Authorization application.

Chief Complaint:  Right hip pain.

HISTORY OF PRESENT ILLNESS:  Mr. Daniel Hahn is a 56-year old man who is consulting me regarding right hip pain.  He has had longstanding problems with the right hip for over 7 years which has gotten progressively worse.  He has difficulty walking and  going up stairs.  He has difficulty getting up from a seated position to a standing position.  Any weight bearing is painful.  He has no significant

… Read the rest

Danny Hahn’s Hip Resurfacing with Dr. Gross 2020 with Carefirst Insurance

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I hope my post gives a path to navigate doctor offices and your HMO insurance to get coverage in other states where hip resurfacing is offered.  As you may know HMO insurance contracts limit the territory to a local region of contracted doctors for your plan.  In the case of my Blue Choice HMO I recognized no contract wording that gave direction for seeking coverage outside of the territory because the service wasn’t available in-network.  Dr Thomas Gross said that because I tried in-network to get a resurfacing, and upon his determination that I was an excellent candidate, he could submit an application with my Maryland HMO for his services in South Carolina.
To me it made sense that an agreement outside of the Insurance … Read the rest

TRICARE APPROVES Hip Resurfacing 2016

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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:
  • Have chronic, persistent pain and/or disability;
  • Are otherwise healthy and active;
  • Have normal proximal femoral bone geometry and bone quality; and
  • Would otherwise receive a conventional Total Hip Replacement (THR), but are likely to outlive a conventional THR implant system’s expected life.

… Read the rest

John Williamson Insurance Appeal Letter at Surface Hippy

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John Williamson January 17, 2006 Harvard Pilgrim Health Care 1600 Crown Colony Drive Quincy MA 02169-9777 Re: Appeal of denied coverage, HP0412161-00 Dear 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 History I have DX with degenerative arthritis of the left hip, which restricted my normal activities. I could no longer walk fast, getting in and out of my car was more difficult and climbing stairs and performing my job was becoming awkward. I’m a single parent with full physical custody of my three children. Caring for my three children, working full time and
… Read the rest

Rod Windle Cover letter for insurance appeal

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November 9, 2007 HMO Help Center Department of Managed Health Care 980 9th Street Sacramento, CA 95814-2725 This 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 appeal of Affinity Medical Group’s decision regarding hip resurfacing surgery was denied by Blue Shield on the following grounds: 1) “…your medical group has affiliated orthopedic surgical specialists who can provide your care.” 2) “…there is not specialty agreement that you are a good candidate for a hip resurfacing procedure…”
… Read the rest

Alan Ray Appeal Insurance Letter for coverage of his hip resurfacing surgery wtih Dr. De Smet in Belgium 2004

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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 component of dysplasia”.  The result

of the condition is that I am unable to engage in the athletic activities that

have helped me control hypertension and maintain extremely low blood cholesterol

levels (as demonstrated in my past two annual

physicals). Despite a high-stress professional position and extremely demanding

work schedules, … Read the rest

Sample Appeal letter to TRICARE

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To Whom it May Concern,

Re:  Appeal # xxxxx

I want to bring to your
attention an inconsistency in the TRICARE policies regarding total hip
resurfacing and FDA-approved devices.  Over the last 6-months I have been
evaluated and clinically qualified as meeting all the criteria and
indications for a Birmingham Hip Resurfacing procedure and I have obtained
the clinical recommendations of (1) two Active Duty Military Treatment
Facility (MTF) Orthopedic Surgeons, (2) a TRICARE Network Orthopedic
Surgeon, and (3) a nationally recognized Orthopedic Surgeon, all supporting
this procedure and this FDA-approved device for the treatment of my
condition.  Unfortunately, the current TRICARE policy does not support this
procedure as being a “proven” treatment and I need your help to change this
for me and all … Read the rest

Michelle Insurance Appeal Information at Surface Hippy

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Dr. De Smet 2006

Insurance Appeals 101

For 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. My full document is 152
pages (8
1/2 x 11″) and was available on the website for my insurance
plan.

(2)Read the entire document (hey you’re probably not
sleeping anyway
if you need a new hip and this reading is much more
effective than a
sleeping pill..), but pay particular … Read the rest

Roger Linfield and Insurance Coverage for Hip Resurfacing with Dr. De Smet

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“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 company (Aetna in this case) to administer the plan. My employer, along with a committee of health professionals, assembled a “Medical Plan” – a specific set of rules on what is and is not covered. Upon reading through the Medical Plan, I couldn’t find anything that specifically precluded coverage for

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