Help - Referral Denied - Time for Battle - Need some ammunition

[hipnhop]

I was schedule for BHR surgery on Tuesday 11/8. I received a call on Monday 11/7 from my surgeon  (Dr Horton of Kaiser) stating that she did not feel comfortable with MOM resurfacing and THR. She informed me that she would not go through with the BHR because of info she received at the Assoc. of Hip and Knee Surgeon Conf. in Dallas that weekend (they must have scared the BeeJezus out of her). She offered me a THR. If I did not accept a THR she stated she would gladly put in an external referral for the BHR to be conducted by Dr. Craig Thomas, an experienced HR surgeon (300 plus) out of Providence Hospital in Washington, D.C . (Dr. Thomas assisted Dr. Horton with my left BHR in March). Today Dr. Horton's referral was denied by her boss, Dr. Maurice Cates, Chief of Orth. at Kaiser Mid Atlantic. I must appeal.

Now I must let ya'll know that I'm from the Bronx and I don't like being a YoYo.  I am three seconds off giving someone a good ass whuppin.  I’m just scared I might hurt my good hip (just joking - bout the ass whuppin).

Rob gave me a copy of an excellent letter he used to appeal.  It has a lot of good information but I need your thoughts on a few issues:

1. Kaiser performed a successful BHR on me in March of this year - so what happened since then? Does anyone know of the release of any new studies they might have spooked them into refusing to do MOM THRs and HRs? If there is no valid scientific data , then why are they denying their patients access to the MOM opportunity.

2. I am worried about my operated hip.  Due to the pain the un-operated  one, I cant fully rehab the way I need to.  Moreover, I am limping profoundly. For people who have Bi-lateral Osteoarthritis, Are there any scientific studies about the impact on recovery in patients with one hip done and the other not?

3 The impromptu cancellation of my surgery directly impacts my current and future income opportunities due to missed/cancelled speaking engagements.  My professional career requires extensive travel and advanced contacting, due to surgery I cancelled all speaking engagements.    In addition, my future work commitments are at risk if the surgery is delayed. 

4. A Famous East coast HR Doc told me that  Kaiser has referred high profile people to him in the past. Would you use this a part of your appeal?  It would be great if I could find the names of these Kasier patients. A little classism going on here?.

5. Lawyers – did anyone have the appeal come from a lawyers office  for more weight?

6. The impact of taking Voltaren for over 1 year. IS my stomach turning to mush? Is there additional risk for me continuing to take this pain killer.

I have all the stuff on benefits on BHR over THR and the need for an exp surgeon – thank to Rob,.  These other points or any others that you can think of will help me craft my appeal.

Thanks
Hip

[Boomer]

Hip,

You may not want to hear this but I'm going to share an opinion. The MOM
issue is a big deal. The agenda for the annual meeting of the American Association of Ortopedic Surgeons is filled with presentations and debates about it. The meeting takes place in SF in February. There are also a number of presentations regarding hip resurfacing vs hip replacement. As long as the medical community is debating these issues, it will be hard for you to make a case with Kaiser. Kaiser, and let's give them the benefit of the doubt here, wants to see the conclusions reached during this upcoming conference. I don't think you can force their hand. I think you will frustrate yourself trying.

If you can swing the financial assets to go outside of Kaiser, you should pick the best damn resurfacing surgeon you can find and get your hip fixed by a pro, not some reluctant Kaiser hack. Lots of folks have gone to India and Begium and had great results for a quarter of the costs.

You can continue putting energy into your appeal, but I suggest you be working on plan b at the same time. I don't see the Kaiser option ending in a happy way for you.

Sorry you are going through this nightmare. Be happy to talk to you offline.

Boomer

[Pat Walter]

I am also very sorry Kaiser is taking such a stand against MOM.  MOM devices have been around a very long time.  I can't help you with info about fighting the insurance company.  The only information I can give is to either hire a lawyer to help you, think about going to Dr. Bose of India for about $10,000 total cost including air fare, hotel, hospital and medical expenses, or find out how much extra it will cost out of Kaiser.  I know Dr. Gross use to be about $25,000 for the whole surgery, so I don't know if there is a way to use some of your insurance outside Kaiser.

The strange part is many of the THR are MOM so you will have to be careful what they give you if you decide on a THR. Don't let them give you an old fashioned small ball metal/plastic THR.  There are some other metals and ceramic - but be careful about getting anything with a small ball.  It is the small ball that allows dislocations and restrictions on your activities.

Here are some other sucessful appeals if you haven't seen them  http://www.surfacehippy.info/insuranceappealinfo.php

I wish I could help more, but I can't.  I opted to put $18,000 on my credit cards to get mine done in Belgium and felt it was a better investement than a car or even house.  We all have our priorities and I understand that.  Please keep us updated.  We can support you, but I don't know how much we can help with your fight against Kaiser except for moral support.

Pat

[ScubaDuck]

Hip-

That just sucks!  To wait until the last second and pull out.  I think I would call a lawyer if your economic damages from lost income are substantial enough.

It also seems to me that Kaiser is working to protect itself not the patient.  Why would they deny a referral to another Kaiser surgeon that does the procedure?  Also you already have one of these devices.  In a sense you are already exposed to the MoM problems they are attempting to protect you from.  Are they saying the first device is fine and the second one will be bad?  Are they offering to revise your first hip to a THR?  I think you need to make them cite the studies they are basing their decision on that show BHRs implanted by experienced surgeons have a higher revision rate than THR.

This whole defensive medicine approach to things pisses me off.  It is the insurance driven, risk avoidance at the expense of the patients.  So let's wait until the patient's condition deteriorates to the point that we have do a bigger procedure.

Best of luck Hip.  Keep fighting!

Dan

[hipnhop]

At this point I am in the battle for the long run.  If I miss this window of opportunity (next three weeks) I am going to have to wait until April/May.  I have contracts that I can't cancel.  At that time I hope some more info comes out from the SF meeting in February.  Until then I am going back on pain meds.  I will explore THR options for the last resort. I'll check out Pat's other site to see what THR options are best for active lifestyles.

Thanks ya'll,
Ed

[Aerial]

I find amazing that they would cancel so close to surgery.  How could a medical professional back out like that?  I think your doctor should finish out HRs that are scheduled and then, with new patients, not schedule the surgery if he/she is uncomfortable.  I am like you, I have waited almost 5 months to have my surgery due to my work.  If I don't get it done as scheduled in December than I would have to wait until May.  I totally get how ready you are to get it done!  Good luck finding a timely solution.

[curt]

      Ed, this is really tough on you, wish it was more straightforward.  I've stated lots of times that I would have done a THR to alleviate my pain IF THERE WERE NO OTHER OPTIONS.  There are.  Things have just gotten in the way of yours in the near term.  There are lots of things you can do with a THR, but as Dr. Gross told me at my checkup, those in the THR group wouldn't believe what his patients are doing with resurfaced hips.  Keep your options open.  Keep your options open.  Best of luck to you in this fight...not of theirs, but yours.  Curt

[Tin Soldier]

Hip - that bites.  I am sort of with Boomer on this in that you are fighting an enormous insurance comany.  Also, if the AAOS wraps up in Feb and all the surgeons walk out of there content, talking about so'n'so's presentation on MoM and how it won them over, and the HR community actually believes in the high success rate of HR, I'm not sure Kaiser or any insurance company would accept HR on the ticket mid plan-year.  Providence and it's controller for my insurance certainly changed things mid plan-year, but not for the patient, but for the insurance company to save money.  Providence essentially added a $500 co-pay for HR because they claim it is of "questionable medical value".  I don't get it.  Still, $500 extra is nothing compared to your situation. 

I said I'm sort of with Boomer, I also want to fight and I think you should keep going if you can.  I think Dan's argument about them protecting you from MoM, is a good one.  Dude - you've already got the dreaded CoCr prosthesis.  I suppose their argument might be that you would be doubling the risk.

What about looking into your State's health insurance commission.  There is probably a board of commissioners that are choosing what types of procedures should be covered by insurance and maybe Kaiser is following their lead?  That's the usual direction that I'm pointed when I go to Providence asking for a study that supports their decisions.  You might also consider talking to a legislator. 

BTW - excellent set of issues to research.  Good Luck

[Anniee]

Ed, I am so sorry you're having to deal with this.  I don't really get how any doctor can think amputating a big chunk of your thigh bone is a better option than resurfacing the joint.  I wish there was something I can do to help.  I sincerely hope you find a solution that is acceptable to you!

[mslendzion]

The first surgeon I went to only did the THR.  Because of my age (46) he referred me to other surgeons that perform replacement surgery.  It made made feel good that he passed up the business for a better lifestyle for me in the long run. 

[hipnhop]

Here's what my surgeon said she would use instead of BHR: "As I told you earlier, I would use a TOTAL HIP REPLACEMENT with cross link poly, large head and ceramic ball. This has the lowest wear after ceramic on ceramic and metal on metal. This is what most people are using on their young patients. In terms of the voltaren, you can take the Voltaren indefinitely, so long as your kidney and liver function is monitored once or twice a year."

Anyone else had this type of THR? Are you running a 4 minute mile now or what?

[Luanna]

Interesting. That's what my surgeon would have used if we had gone THR. We went with the HR using metal BHR on Stryker X3 poly acetabular cup, but he would have preferred ceramic ball on the cross linked poly but the ceramic ball for HR was not available. My guess is that your surgeon is looking at something similar to the Stryker product linked to below.

Here is a link to the Stryker THR large head ceramic ball with cross linked poly acetabular cup:
http://www.stryker.com/en-us/products/Orthopaedics/HipReplacement/PrimaryAcetabular/mobilebearing/139617 

Optimally, it would be great if you could get a HR with the components that best fit your body and needs. Someday maybe. The old poly had lots of failures but the cross linked poly seems to be proving to be much stronger. My surgeon is impressed with the cross linked poly wear results. He says that alot of people think about the past and the older poly and the failures that resulted from it and have written poly off completely.

What are you going to do? Have you made a decision yet?
Luanna

[hernanu]

Keep your chin up, hip - you'll get what you need, just may need to be April instead. Sorry they're riding you on this.

[hipnhop]

Luanna, Thanks for asking. I am going to appeal the denial. I just dont know how long it will take to get an answer. In the meantime I going to research all other options. I'm hoping to speak to some THRs triathletes to get their point of view. I am also looking at going to India.

I'll keep you guys posted.
Hip

 

[Woodstock Hippy]

India just might be your best option right now.  At least you'll know that you're going to one of the most highly regarded surgeons.

[ScubaDuck]

Hip-

I thought about India as an option.  But then when I found out one of the most experienced surgeons was covered by my insurance, it was an easy choice.

Keep up the good fight. 

Dan

[David]

Hey Ed, sorry to hear of the troubles you are going through...
Regarding THR and triathletes, you may wish to contact Roch F., he is listed under members here as RF.  He had to have his BHR revised to a THR this year after a crash in a bicycle accident.  I'm sure he could shed some light on the issue for you.

Best...
David