Category Archives: Insurance Appeal

TRICARE APPROVES Hip Resurfacing 2016

Hip Resurfacing Information at Surfacehippy Posted on by

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

    Hip Resurfacing Information at Surfacehippy Posted on by
    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 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
    … Read the rest

    Rod Windle Cover letter for insurance appeal

    Hip Resurfacing Information at Surfacehippy Posted on by
    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 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
    … Read the rest

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

    Hip Resurfacing Information at Surfacehippy Posted on by

    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 … Read the rest

    Sample Appeal letter to TRICARE

    Hip Resurfacing Information at Surfacehippy Posted on by
    To Whom it May Concern,Re:  Appeal # xxxxxI 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… Read the rest

    Michelle Insurance Appeal Information at Surface Hippy

    Hip Resurfacing Information at Surfacehippy Posted on by

    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
    … Read the rest

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

    Hip Resurfacing Information at Surfacehippy Posted on by
    “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

    … Read the rest