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…” 3) “…(there is not specialty agreement) that this procedure would be superior to a total hip replacement.” 4) “…there is no medical documentation leading to the conclusion that a Blue Shield affiliated specialist cannot provide the specific medically necessary services that you require (whether total hip replacement or approved resurfacing procedure with the Birmingham prosthesis).” 1) It is the opinion of the affiliated surgeon performing HR within the network (Dr. Huddleston) that I am not a good candidate for resurfacing (exhibit 1). Dr. Huddleston has wisely self-selected out of consideration as the surgeon who performs my resurfacing. Accordingly, there is not an ‘affiliated orthopedic surgical specialist’ who has the qualifications and the experience to proceed as a HR surgeon in my case. 2) Exhibits 4,5,6 and 7 are from four separate physicians, each of whom independently supports my request for resurfacing. Exhibits 4,5 and 6 contain diagnostic conclusions and treatment recommendations from orthopedic surgeons who are hip resurfacing specialists. All three conclude that I am an excellent candidate for hip resurfacing. It should be noted that the individual experience level of each of these specialists (Dr. Sparling with 120 resurfacings, Dr. Ure with 300 resurfacings, and Dr. De Smet with 3000 resurfacings) far surpasses the experience level of the Blue Shield affiliated specialist, who has completed approximately 15 resurfacings. Exhibit 7 is from my personal physician who, while not a hip specialist, understands the medical science and the issues involved. Specialty agreement does, in fact, exist that I am a good candidate for hip resurfacing. 3. There is, in fact, specialty agreement that HR is superior to THR in my case. That is why it has been recommended by the physicians listed in (2), above. Evidence of the superiority of hip resurfacing for younger, athletically active males such as myself is voluminous, increasing daily, and evident to anyone, lay or professional, who is up-to-date in the field. THR is an inferior medical solution in my case as I can reasonably be expected to outlive a THR, resulting in at least one difficult and costly revision. Of greater importance is the fact that a THR will place unacceptable restrictions on my lifestyle and on my athletic activities. There will be no restrictions placed on my athletic activities post-surgery by any of the three surgeons who have diagnosed my case and who support resurfacing. The research cited in the exhibits below confirms that ‘no restriction’ is the majority view, supported by over 90% of resurfacing surgeons. A medically “superior” treatment is the one that will help to create the highest possible quality of life by restoring health and function. For me, longevity is not the main issue in determining quality of life. It would be far more desirable for me to have ten years of future activity free from medical restrictions than a lifetime with the limitations a THR would impose. The superiority of resurfacing can be quantified not only in terms of quality of life but also in terms of future cost containment. Medical realities and associated cost savings include: · reduced risk of dislocation, resulting in potentially fewer medical interventions · conservation of bone stock for future revision (if necessary) which can be expected to result in a lower-cost, more satisfactory outcome than revision from a THR · freedom from medical restrictions will translate into reduced future medical expenses, as participation in desired sports and exercise will promote both physical and psychological wellness. (exhibits 3,8,9) Any of the specialists who support resurfacing in my case can provide detailed additional information to support the superiority of resurfacing over THR in my particular case. 4) Recent research findings indicate that those who perform hip resurfacing surgery require substantially more experience than formerly believed in order to become proficient. At the present time, the affiliated specialist does not possess the basic level of experience research indicates is necessary. Thus, even if the affiliated specialist believed he would be able to perform HR in my case, there would be serious questions as to whether he had enough experience to do so. Accordingly, his decision to decline to offer HR surgery in my case is appreciated. (exhibit 10) It should be noted that exhibits referenced above which consist of journal or other articles are representative, not exhaustive, of the topics covered. It is expected that reviewers will be familiar with the breadth of the literature and will perform their own review, as necessary, to bring themselves current. Thank you for your consideration of my request for an IMR. Sincerely, Rod Windle, Ph.D.