Authorization / Rehabilitation

[courtpt8]

Hello Everyone-
I just underwent Stage I surgery 07/17/2008 at which point they determined that I will need to have deNovo (similar to ACI, but using juvenile tissue instead (see previous entry), medial meniscal transplant, +/- ACL revision (original in 1993, but is now "loose"). 
I was just curious:
1.)  How long do most people have to wait to get insurance authorization between surgeries when you have both
      a meniscal transplant & ACI?
2.)  I presume the rehab scheme will follow that of a meniscal transplant versus ACI...Does anyone have a protocol for the rehab??
3.)  What is typical insurance coverage for these procedures (for those of you whom have already been through this)??
      Does insurance hold to the "typical" coverage, or do they add in "extra charges" due to the complexity of things?  (ie if I have a $250 co-
      pay for surgery, is it just $250, or do you end up paying more on top of that???
Sorry for so many questions, but I am just trying to "get all my ducks in a row" & figure out what to plan for when the authorization / approval actual comes through. 
As far as scheduling goes, does anyone have any suggestions?  I know this may sound crazy, but I am a huge Christmas fanatic & am trying to plan so that I will DEFINITELY be able to have decorations up for Christmas (even if that means decorating in September  ).
Thanks everyone for your input, it is greatly appreciated for those of us "rookies" who have nothing but the unknown to look forward to.

[Chondrosoldier]

1) What part of your knee is your ACI being done on and who is your insurance carrier?

2) The Zimmer/Isto client rep you're dealing with surely has a rehab protocol.  Call them.  I doubt you'll find a whole lot online with regard to Denovo rehab because its so new.

3) Call your insurer and get a copy of their medical policy on ACI and Denovo.  There is no "typical" case.  Your insurance will either nitpick the policy and engage you in a  fight or your case will go right through.  This is mainly determined by the ICD-9 codes your surgeon uses when submitting the case.  A common one is patellar ACI, which a lot of insurers kick out; thats the main one you'll hear about on here.

Copays and Christmas ornaments should be the last thing on your mind.  #1 priority should be working with your surgeon's office and talking with your insurance to make sure it goes through without problem.

If your insurance does fight it, its because the surgery and rehab are billed to insurance at roughly 600x that $250 copay.  However, your in-network Maximum and out-of-network maximum are what you will end up paying (along with deductible percentages until you hit max) and you will max it(at least the in-network part of it).  These vary highly with different insurers.  Don't worry about it, just get the surgery approved.
 

[dileigh]

How long usually depends on the insurance companies, you will still have time after the approval because it takes a few weeks to actually grow the cells.   That isn't done until then for regular ACI, I'm assuming it will be the same for yours.

Check with your insurance, are you sure that's the copay or the deductible?  If it's a deductibe there may be more money that you have to pay out.

I would still expect the rehab to be like an ACI, it sounds like all that's different is the source of the cells, unless I'm reading it wrong.


Diana

[skierboy]

I'm surprised that this topic isn't generating over half the conversations on this site.  My recent experience is with a Blue Cross affiliate on the East Coast.  One of my orthopedic surgeons recently got denied insurance reimbursement from two different insurance companies for the DeNovo NT work he did on two of his patients.  But he had no hassles in getting insurance coverage on some other patients who were covered by different insurers.  The key problem is that some (or all?) of the companies will not give either the insured or the medical provider a clear advance answer as to whether the DeNovo NT procedure will be covered by the particular policy or not.

I called up the Customer Service dept. for my health insurance company and got the typical very friendly person on the line who was very positive--untill I asked to get copies of the medical policies of the company regarding knee surgery procedures.  Suddenly silence.  Ultimately I was given an "inquiry number" and told they would get back to me.  They did yesterday and basically provided me with nothing along the line of medical policies.

I was told informally by a physician's administrative assistant that these insurance company medical policies are only available to people who have been given permission to see them and who have an "account" with the health insurance company.  My impression is that most health care providers (i.e., the doctors) don't get access to these policies--in part because they are spending their valuable time treating patients.  So for the insured as well as for the medical provider (and facility), it is like playing Russian roulette as to whether a relatively new medical procedure like this will be covered by health insurance or not.

So I started googling to see if I could crack the code.  I was surprised to find out that (at least as regards many Blue Cross affiliates) these medical policies are available on line--even though the insurance companies seem to go out of their way to NOT make it easy for their subscribers to find them or to even know that they exist.

As to where various Blue Cross affiliates stand on DeNovo NT, I'd have to say they are all over the place.  At least one affiliate definitely categorized the implantation of loose chips of articular cartilage (whatever its origins) in the knee as "investigational"--which is the kiss of death phrase from an insurance perspective.  Many of the affiliates had not brought their policies on knee surgery up to date enough to even address a procedure like the DeNovo one.  I am hoping that one may be able to make a credible argument that DeNovo is "medically necessary"--the breath of life phrase from an insurance perspective--so long as it appears to be the best medical option for the orthopedic surgeon and his patient, given the cartilage condition of the patient.  This argument will only work if your insurance carrier has not yet issued a medical policy nixing DeNovo or any similar procedure.  And you will probably need to muster some good paperwork to substantiate your arguments as to why you should not be condemned to a knee replacement when you still have good cartilage separation between the leg bones at the knee and simply have some cartilage defects that need repairing.

[ajschnelk]

I'm currently going through this right now with my carrier.  I am in the middle of my 2nd appeal to my insurance company for Denovo NT for a trochlea defect.  I am 15months post ACI and it has been considered a failure due to a fairly large intralesional osteophyte that formed under my graft.  Regarding the procedure code, I have it and can share if you need it.  I got it from my doc, but I also found it when pulling info off the web from Zimmer.  My policy states that it's  considered "experimental" and is not allowed.  However,  I have two thing going for me...My doc is the one of the leading docs with Denovo (performed the first one and has done more than any other doc) and two, my policy is  "self insured", so my employer can override their decision if it comes to it.  I find it comical that they will okay ACI for a second time for an additionalf $30k-$40k when compared to DenovoNT.

skierboy, what is your situation?   

[skierboy]

AJ--

I'm a federal employee with Blue Cross coverage under the Federal Employee Program.  It sounds like you are trying to get a "guaranty" from your medical insurance company before getting the DeNovo NT implant done.  My orthopedic surgeon tells me that most insurers will never guaranty any payment, which is why both the patient and the medical professional (and the center where the outpatient surgery is done) are at risk if the procedure to be followed is not recognized as "medically necessary" by the insurer.  The patient is often encouraged by the Customer Service office for the insurance company to go ahead and have the work done since they don't really understand what the DeNovo NT material is and how it is implanted.  Only after the fact do they recognize that it is somewhat cutting edge and thus suspect.

At this point I do not anticipate getting any kind of guaranty from the insurance company.  I'm willing to absorb the cost of the procedure and ensure that the doctor and surgery facility get paid.  Then I'll file a claim against my medical insurance company to recoup the funds.  I may succeed; I may not.  Since the insertion of "minced juvenile cartilage" is not specifically called out by my company's medical policies as "investigational only", my odds should be pretty good.

One thing I'm curious about and haven't gotten a clear answer on yet.  Perhaps you or someone else would know.  If I have my knee rehab procedure done in the Blue Cross jurisdiction in which I live, the claim is handled by my local Blue Cross affiliate.  But if I have the procedure done 50 miles away, or in a more distant place like Kansas (to pick a state), I believe the allowability of the procedure would be judged by the policies in the locale where the surgery was performed.  I've had a couple of medical charges over the years (either for me or for another member of our family) that were processed through another Blue Cross affiliate--in all cases because the medical work was done out of our normal area.

In such a case, is it possible to "forum shop" in order to try to have the surgical work done in a jurisdiction where the affiliate's medical policies appear to be more favorable--or at least do not directly cite the DeNovo NT cartilage rebuild method (or some generic equivalent) as "investigational" only?