Denied Coverage

[lorndav]

I am 42 female with OA in both hips. I was scheduled to have BHR Sept 11th for the R hip. However, the day before yesterday I got "the letter". My insurance company has denied coverage becasue they consider it investgational. Does any one have any advise? We have started the first appeal. Any experience if these are ever successful? Any advise would be appreciated.

[Pat Walter]

Hello

Unfortunatley many insurance companies are difficult to deal with. The BHR surgery was approved by the FDA in May of 2006. It is no longer investigative.  Here are letters how other people fought their insurance companies:
http://www.surfacehippy.info/insuranceappealinfo.php

You can see toward the second half, the medical policy by many insurance companies about hip resurfacing.  Many are starting to cover it. 

You need to appeal their decision and continue to fight with them.  If you can't win, then your option will be to travel to Belgium or India like many of us have done to get our BHRs.  I could not get health insurance and had to pay for my hip resurfacing. It was $16,000    Some have gone to India for about $10,000 to $12,000  Both Dr. Bose in India an De Smet in Belgium are several of the very best in the world.  Sometimes we just have to pay for what we want.

Please take time to read the stories and information on the page above. It might really help you.  Some people have had to do several appeals.  It is not fair, but I guess life is not fair sometimes.

Good Luck. You are way too young to accept a THR.

Pat in Ohio
3/15/06 LBHR De Smet

[momzer2]

Good Morning:

I also am currently 'fighting' my insurance company for a BHR.  I am scheduled for surgery 9-18.  I am a 48 y.o. female with hip dysplasia and end stage osteoarthrosis of the left hip.  My right hip is still a few years away from needed the procedure.   I have some really good letters that are straight from several insurance companies that I received from the Smith and Nephew Rep.  These are policy statements from several ins. co. that are now allowing the BHR and WHY THEY ARE.  My ins. is still in the dark ages!!  However, my employer is self insured and they have the ability to 'override' the ins. co.  Who is your insurance company?  I believe the letters I have are from Humana, Cigna, Aetna, United Healthcare, and I think one other.  Let me know if you want me to e/m them to you.   DO NOT accept a THR.  You are WAY to young for that!!   

Karen

[73Hippy]

I was wondering if the person (Karen) who did reply #2, with the letter from Cigna could forward that to me.  I happen to have Cigna Ins.  I'm just in the process of making sure that this procedure is covered. 

I'm 52, very active lady & very tired of hurting 

Thank you

Lori

[momzer2]

Lori,

Sorry I haven't replied to your request sooner.  I just had by LBHR on 9/18 and I haven't been on-line a lot yet.  I will try to e/m the letter to the site.  Also, is your company self-insured?  This is the only way I got my surgery covered.  Let me know if you have any other questions.

Karen

[73Hippy]

Thank you for replying, actually it has already been pre authorized.  Thank goodness 

Hope all is well with you.  I'm having mine done 11/5, so looking forward to walking normal again in the future.

Happy Pain Free Holidays

Lori

[Terry_Smith]

  Well, it seems BCBS of Massachuestts has also denied my surgery, though I haven't been given any reson other than because of "policy guidlines".  Not sure what that is yet, though it could be several factors, such as, that I'm overweight, cysts around the femoral neck, close to 45% of the femoral head gone ( and getting worse each day).  I have my companys HR looking into it, and am waiting for the "letter" to see my next step.  So, it's very possible that a full THR is in my near future for both hips.  They are really hurting now, and I'm not sure I can hold out to see the results of any appeals. Plus, by the time I get the appeal won (no guarantee) my bone loss may make the HR a non-viable option.  That being the case, I'll go for the large diameter MOM.  Dr. Ball suggested a "modular" approach, being titanium with a thin shell of the cobalt chrome, so that if I have a reaction, the shell could be removed, but that means a small ball, and I'm trying to not go there.  This really bites the big one, but I think I'm screwed as far as the insurance is concerned.

Terry

[Pat Walter]

Hi Terry

I am sorry to hear about your insurance company denial.  I don't know why these insurance companies are giving people such a hard time.  I hope your company can help you out.  It is a shame to get THRs when you might have hip resurfacing.

I wish you luck in your battle and hope things will still turn out OK for you.

Pat

[Terry_Smith]

  According to BCBS of Mass, they won't consider HR a viable alternative to THR until their policy changes in February of 2008.  Until then, it's considered "investigational".  If I had the time, I could either wait until their policy changes, or file an appeal with supporting documentation to try to get them to change their minds, but in all honesty, I can no longer wait as my hips are just about unuseable.  So, tomorrow I schedule for MOM THR, large diameter ball.  To be honest, with my hips feeling the way they do, and seeing how my hips wore down in 1 month on the x-rays, it will probably be almost 2 months from the last x-rays til now, and most likely, my hips are too worn for HR at this time.  Time just wasn't on my side.  I can barely do my job right now as it is, and it's only getting worse.  I've got to get these hips fixed, and fixed ASAP.  Thank you so much for the knowledge I've gotten here.  I'll still recommend anyone I find to get a BHR before a THR, even though I won't be able to get one.

Terry

[Terry_Smith]

Update:  I got the "letter" this morning, and they won't approve the surgery because I'm overweight, and it would decrease the long term benefits of the procedure.  Anyhow, I am almost unable to walk as it is, and since my surgery date for the THR is Jan 16th, I do not have time to a) lose alot of weight, b) file an appeal with supporting info from others who are heavier and have had success with the procedure.  To be honest, my hips were "iffy" a month ago, and right now, I'm amazed I'm even getting around.  In fact, I'll probably have to take some vacation time before my surgery as it's very painful to get around to do my regular job as it is.

Terry

[Pat Walter]

Hi Terry

Again, I am sorry to hear that you are being denied your hip resurfacing, but getting a couple MOMs is not a terrible solution.

The size of the device will be the same as BHRs so you should not have any dislocation problems.  Getting out of pain and being mobile again seems to be the most important thing now.

Please keep in touch either here or at Total Hip Talk.  We are interested in hearing how things are going for you. 

Sounds like you definetly need some new hips and you need to take action as soon as you can.

Merry Christmas - if you are into that and I wish you the best of 2008 with new hips and no pain.

Pat

[Terry_Smith]

Pat,

   Thanks for the reply.  Yes, I agree that MOM's are better than the old alternative, and I've already signed up to your other site, so I will be posting on there going forward.  I still would've preferred keeping more of my own bone, but, if I can get 20+ years out of these I'll be happy.  Merry Christmas to you and your family as well.

Terry