The story of my Successful request to my HMO to cover surgery in another state.

dannythebeerman · November 20, 2020, 05:07:54 PM

This is a story how I saved a bunch of money getting a hip resurfacing. I didn't have to buy broader coverage that guaranteed out of state coverage, just allowed the surgeon to explain to the insurer that I couldn't get it by a proficient surgeon in my home state. Unfortunately there are not many surgeons on this earth performing hip resurfacings, it is likely one would have to travel to another state to get this operation, your cost for this surgery doesn't have to be prohibitively expensive compared to having surgery near your home, other than travel, meals and lodging. My out of state HMO covered surgical expenses from one of the best and most experienced Doctor in the world. Not many in this forum have been successful in doing this. I got lucky (there was a little attention of detail to the application that gave this luck but it wasn't hard) and hope you may find your hip replacement resurfacing future as lucky as mine.

https://surfacehippy.info/hiptalk/index.php?topic=6713.0

dannythebeerman · January 05, 2021, 11:01:10 AM

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 injury. The patient has groin, front of thigh and side of hip pain. He has taken Ibuprofen, Tylenol, and Celebrex. He has had over 30 therapy sessions. He has had cortisone, Synvisc, and PRP injections as well as trigger point injections. He has had no previous surgery. The patient has difficulty carrying over 50 lbs, walking, bending over, yard work, property maintenance, and carrying any extra weight. He has had to walk with 1 crutch, He has been advised to have a total hip replacement, but he would like to be able to sustain falls, run, ski, and play basketball and this is really not possible with a total hip replacement. Therefore, he desires a conservative hip replacement. He has severe pain, 7/10 on regular days and 9/10 on worst days. He is unable to walk except with a crutch. He can only walk about 2-3 blocks. He has difficulty with stairs and shoes and socks. He can sit in only certain chairs. He is able to get in and out of a car. His UCLA activity score is 3/10.

Past medical history is negative for any significant medical problems.

PHYSICAL EXAM: Height is 5'10". Weight is 190lbs. BMI is 27. The patient has restricted motion and pain with range of motion of the right hip.
IMAGING: The patient submits AP pelvis and Dunn lateral of the bilateral hips which show severe osteoarthritis of the right hip with pelvic tilt away from the right hip and superior erosion with superior acetabular bone loss and femoral head bone loss. Despite this, radiographic leg lengths are approximately equal.

IMPRESSION:
1. Severe osteoarthritis of the right hip.
2. No significant medical problems.

DISCUSSION: Mr. Hahn is an excellent candidate for right conservative hip replacement. To get rid of his hip pain, he could have either a total hip replacement or a conservative hip replacement. At his age, a conservative hip replacement carries several advantages. First, functional quality of life is higher. He will be able to return to all of his desired activities mentioned above including impact sports, which is not possible with a total hip replacement. Also, a conservative hip replacement is more durable, currently my 13-year implant survivorship is 99.5% which far surpasses that for any published series for total hip replacement at this age level. Third, hip stability is better. Fourth, there is bone preservation. Finally, 10-year all-cause mortality is less with a conservative hip replacement than a total hip replacement. For all of these reasons, conservative hip replacement is superior, especially for a man of his age and his desired return to activities. He has gone to see Dr. Mike Jacobs in Maryland who used to do conservative hip replacement but is no longer doing this. To my knowledge, there is no surgeon in the Maryland area who is accomplished in this operation, therefore, the patient needs to go out of network for conservative hip replacement and I would be happy to perform this for him. I can perform this as an outpatient procedure and the overall cost would be about $28,000 paid in advance. This is likely to be less than the cost that Blue Cross HMO pays for standard stem total hip arthroplasty. I will have Nancy call him. We will tentatively schedule surgery, and request coverage from his insurance company. Because he is in an HMO, they will likely deny, and he will need to appeal. The reasons for appeal are stated above in this letter. If the patient does end up coming here for surgery, he has a nephew who lives in Columbia, South Carolina who he can stay with for a couple nights before he returns home to Maryland.

Thomas P. Gross, MD/pm