The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: blackbeltgirl on April 19, 2006, 09:30:11 PM

Title: Insurance help - experience with VA Insurance Commission??
Post by: blackbeltgirl on April 19, 2006, 09:30:11 PM
My ACI surgery was denied by my insurance company.  Again.  This time by an outside reviewer.  Apparently, despite being FDA approved in 1997, Blue Bross still considers this procedure to be experimental or investigational.  I haven't seen the letter yet, but my dr's office is NOT happy. 

BUT, my OS is in NJ, and I live in VA.  Has anyone had any luck using the the state Bureau of Insurance?  Is their external appeal the same as the outside review processed through my insurance company?  Were they helpful? 

My dr's office has exhausted the appeals they can process, so now I need to figure out how to get BCBS to pay for me to have this surgery, so I don't end up with a TKR before I hit 40.

Any and all advise will be appreciated.  Do I need a laywer?  Are there patient advocate groups you know of?  Etc. Etc. Etc.

Title: Re: Insurance help - experience with VA Insurance Commission??
Post by: Heather M. on April 20, 2006, 12:21:58 AM

I don't know about the laws in either state, except that Virginia (from my memory of living there) seemed to have legislation skewed toward business rather than consumers.

My advice would be the economic argument--show them that it would cost less in the long run to do the ACI than a TKR.  If that can't be proven, I'm not sure that you would have a convincing argument...except to say that your DOCTOR and not a bean counter at the insurance company should be making your medical decisions for you.  So that would require serious research into a patient's bill of rights.  There is tons of information buried on the Net in the form of chat rooms where people relate their experiences with the insurance companies.  Intensive Google searches might be helpful.

I was also thinking that perhaps the Genzyme folks themselves could be of some assistance.  They want their patented procedure to be as widely done as possible, so it's in their interest to broaden the acceptance of ACI in the insurance industry.  They likely have people whose full time job is to work on issues just like yours, so I would start there.  It's going to take a lot of legwork, I'm sure.  Here's an example from the carticel web page discussing insurance approval and their patented procedure:

You also have a right to the full details of BCBS's appeals and grievances procedures/policies, in writing.  Make sure you exhaust these before doing anything outside of that, because they can nail you for it--and say you haven't followed the rules.  A lawyer may be helpful, but I'm not sure if that would be a cost effective option.  It's possible your legal fees might exceed any insurance benefits you might get.  So you have to find a lawyer or group of them (class action suit) that is in it for the chance to change national policy and set legal precedent.  Patients' rights organizations would probably be a good way to go--what about checking with the American Arthritis Association as well?

And your state insurance commissioner could probably be very helpful--they usually have offices that employ folks whose job is to deal with consumer issues.  I would also think it would be important to find out if BCBS approves Patellar ACI in any of the 50 states--that sets a precedent that's hard to argue with, but it's time-consuming for the patient to do all that research.  Again, the Genzyme folks should be able to help here.

The place to make your argument and challenge BCBS would probably be along the lines of a) ACI is more cost effective and provides a better long-term outcome, b) ACI is approved for other parts of the knee, c) Some specialists (Minas & Gillogly for example) are doing ACI on patellar defects that have success rates comparable to those for ACI in other parts of the knee that are BCBS approved, so you could argue that they are using old information and data to deny a procedure that has been refined a great deal over the last few years.  Basically, erasing the medical basis for their refusal, which is that ACI for patellar defects is very expensive and has a success rate somewhere in the 30-40% range.  That's why it's still considered by them to be experimental--because it doesn't show demonstrably better results than conservative arthritis management, both because of the risk of significant complications and because of the relatively low success rate shown by previous studies.  By success rate I mean controlled clinical trials with objective, numerical criteria showing improvements in pain levels and function for patellar ACI patients.  Those studies weren't around a couple of years ago, when most insurance companies set their policies for ACI done in areas other than the femoral condyles.  But they should be around now--doctors like Mnas and Gillogly both publish their results.

The main issue, as I see it, is that for now patellar ACI is still considered "off label" by the FDA.  That's because to get the accelerated FDA approval the company sought, they ONLY submitted paperwork and clinical trial results for femoral condyle lesions (I think that was the original use, but it might include the tibial plateau as well--you'd have to check the Genzyme product "label" for the exact indications-- try here for the actual label: )

This means that any use other than that which was approved by the FDA is considered "off label."  So it's exactly the same as, for example, Viagra being used for female infertility issues:  doctors know it works for certain uterine problems that impact fertility, but this was NOT the use for which Viagra was approved by the FDA.  So every insurance company out there will refuse to cover fertility treatments that involve the use of Viagra for the female partner.  Doctors know it works, and are doing trials to PROVE it works.  But until then, patients are stuck paying for this themselves.  Same deal with patellar ACI. 

Good luck and keep us posted.  Hopefully you'll find other folks out there who have done a lot of the legwork, because this has to be an issue that many people have confronted in the last few years.

Title: Re: Insurance help - experience with VA Insurance Commission??
Post by: soccerdoc on April 20, 2006, 02:31:36 AM

THis is very good stuff Heather M has written.  You and/or your physician are entitled to see the data used for the decision-making.  In dealing with similar rejections for spine surgery patientsw it was often necessary to provide exhaustive references.  Even then on occasion patients were referred to the ombudsman in the insurance commisioner's office.  Different states operate their insurance commissions differently in my experience but finding out what the procedures are can be help you plan your strategy.  Be persistent and document any and all phone calls to BCBS, the insurance commission etc.  Hang in there.

Title: Re: Insurance help - experience with VA Insurance Commission??
Post by: blackbeltgirl on April 20, 2006, 02:33:01 AM
Thanks Heather.  I don't need BCBS to approve petaller aci, since none of my lesions are on my patella.  Actually, the lesion with the best odds for approval is the trochlear lesion, since it's within the size specs of the carticel label.  I have been working with genzyme all along, but my OS has a great track record getting this stuff approved so they let the dr's office take the lead till now.  I'll call my case rep again tomorrow.  And I've already left a message at the state insurance bureau.  I will probably file an external review, and see what that gerts me.  I need to submit the request for all data in my file, to see how they've managed to argue that aci is not fda approved.  My guess is that the "on-label' use is for the trochelar groove and femoral condoyles, and lesions up to 10 sq cm.  WIth a tibial lesion, it's off-label use.  And the main lesion was 18 sq cm a year and a half ago, the last time anyone was inside my knee, so the size makes it off-label.  But their letter was pretty vague, and just claims the procedure is experimental.  That may end up working in my favor, who knows.  As to legal advice, I have a couple of friends who do litigation work.  Neither specializes in insurance cases, but both will be able to help me.  My OS is in NJ, so his office doesn't have any experience with the VA insurance board.

Thanks for the tips - I will follow through on all the new ideas.

Title: Re: Insurance help - experience with VA Insurance Commission??
Post by: Teresa_S on April 20, 2006, 04:19:42 PM
Hi, don't know that I can be of much help, as I have not been in the middle of all this for awhile. BUT ,when Blue Cross Blue Shield was the main insurance for most groups, it had something called reciprocity. This meant that they paid in accordance with the codes, etc, and if a large amount was left unpaid, the patient was not responsible , the provider had to refile and show reason or cause, multiple diagnosis, procedures, etc why it was worth the amount they charged, even if it was only a problem they encountered that prolonged the procedure. WHen I took my child to Mayos Clinic, to have open heart surgery, we had blue cross blue shiled of Mo. BUT the way the company was set up, the Blue Cross Blueshield of Minnesota, paid, and then Blue Cross BLue Shiled of Missouri reimbursed them. So, if the company still works that way, you might be able to see if Blue Cross Blue Shield of Virginia would pay for the procedure, and then only the reimbursement would fall to yours personally, and the two states would have to battle it out about the approval of the procedure if Virginia does pay for it.

THe BIGGEST problem with insurance companies anymore, IS THAT they are becoming third party payors, intead of actual insurance carriers. The state insurance commissions have NO aurthority over the third party payors( another reason for them), as they are only controlled by the Federal government, so anything with them has to go through the court system. THese type carriers have a company that is set up to pay their claims, another to process them, and they lease or rent a list of providers for other companies. THEY ARE IMPOSSIBLE TO WORK WITH> THEY are , like I said , not subject to state insurance commissions, so they don't have to abide by their rules, they can make their own. When I first discovered that is what we have, the actual company were still calling themselves insurance, but they are not, I took them to task, and they now call themselves third party payors.Usually, if the case lands in court, the judge will go ahead and follow the commission guidelines as these companies are supposed to be their health insurance carriers.

Unfortunately, the time of companies actually helping their members seems to be abating. Nobody cares that the member may be suffering. THEY want to NOT PAY for any and everything possible. THE less they approve, the less they pay. ONE of my pet peeves is that people who have no insurance can go to the same hospital as me, and pay a cash amount LESS than what I pay in copays and deductibles, let alone the amount we pay in premiums. ALSO, the AMA strongly warns all physicians against abandonming or denying the uninsured or those with state aide. THESE people get many more choices than I do, as I am completely controlled by the insurance PPO. Physicians are so sick of being told what they can and can't do, how long their patients can be hospitalized, which meds they can use, etc. IF they do not belong to these PPOs they are out of the physicians considered by large groups of people who have it, but when they do belong, of course, they have toabide by the rules. Most insurance companies will not go to the trouble to defend its participants.

I would be careful trying to work around, but wanted to offer you the suggestion about the intra states and paying. What I have found with appeal procedures is that they usually pay litlle mind, just write : Previously considered.

Good Luck, Teresa
Title: Re: Insurance help - experience with VA Insurance Commission??
Post by: blackbeltgirl on April 20, 2006, 06:41:25 PM
Thanks for the tip Teresa.  I'll have to do some research.  Several years ago, when the insurance regulations were relaced, BCBS incorporated indepdently in each state.  In VA they don't really use the BCBS, they are Anthem Insurance, BCBS of VA is the "subtitle".  At any rate, the insurance approval was submitted to Anthem, not BCBS of NJ. 

And I just spoke to the insurance commission, and my company has a self-funded plan.  Which apparently means all of this is moot.  I can appeal to my corporate benefits administrator, but that's about it.  Oh well.  Off to do more research.

Thanks everyone-