KNEEtalk

The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: sneakypetes on September 08, 2012, 01:39:37 AM

Title: Need ACI of Patella insurance help!
Post by: sneakypetes on September 08, 2012, 01:39:37 AM
Hi everyone. I'm new here but old to knee pain. I'm a young (used to be) active 48 y.o. with a focal defect grade 4 of my patella. My pain is constant and interferes with sleep,any activity,even sitting here & typing @ the computer. I've had 2 surgeries in the knee: scopes-one withe a lateral release and the last to harvest cartilage for the ACI that my OS says I need. However...BC/BC keeps denying me. I've exhausted my appeals through my OS. I keep up my PT like a good patient but I can't "live" like this. Its affecting  my back now & I'm developing bursitis as a result of walking (limping) funny. Anyone have success with a difficult insurance company or have any hints for me on how to proceed? Thanks.
Title: Re: Need ACI of Patella insurance help!
Post by: Teacher2Many on September 08, 2012, 03:09:16 AM
Is it BCBS?  If so, PPO or HMO?  I'd have your surgeon contact them directly.  I had bilateral ACI done 3 yrs. ago with BCBS PPO and had no problem with insurance approval.  I believe my surgeon's office submitted paperwork to them-journal articles about the procedure, info on my particular defect, success rates, etc.  If he didn't do it beforehand, I know they said they would submit it to them for reconsideration of the claim. 

Are they saying why they're refusing to cover it?
Title: Re: Need ACI of Patella insurance help!
Post by: sneakypetes on September 10, 2012, 08:29:31 PM
Yes,it's BC/BS PPO which is usually great. My OS has been taking care of the submissions and appeals;did a peer to peer with no luck. At this point BC/BS says the providers have exhausted their appeals but I may have further appeal options. The reason for denial is that ACI is 'experimental & investigational" and that it has not been approved for non weight bearing joints (patella). I am BC/BS of IL. What state are you?
Title: Re: Need ACI of Patella insurance help!
Post by: Teacher2Many on September 11, 2012, 12:35:23 AM
I too have BC/BS PPO of IL & had approval for my surgery within 2 months (scope/biopsy to seem ACI was needed was in 1/2009 & I booked surgery in 3/2009.  No problems, no nothing-really surprised to hear this, especially since I had grade 4 defects of the patella as well.  Who's your doc?
Title: Re: Need ACI of Patella insurance help!
Post by: sneakypetes on September 14, 2012, 08:41:43 PM
Dr. Brian Cole. Who was yours,and how are you doing now? I don't know what I will do if I don't get approved. I can't stand the constant pain- this is crazy that there is a treatment but I can't get it.
Title: Re: Need ACI of Patella insurance help!
Post by: Teacher2Many on September 15, 2012, 02:38:51 AM
Same phenomenal OS for me as well!  Not sure why the difference in approval with both BC/BS PPO and both the same OS.  Hopefully things will get approved shortly.  If not, I'm sure there are other procedures that they can do/try-microfracture, OATS, denovo for cartilage issues and sometimes just a TTO helps w/the pain by shifting the loading forces of the patella.

They approved my bilateral ACI very quickly and then even approved bilateral OATS less than a year later (which ended up not being needed or done, as the cause of the continued patella pain had nothing to do with a failed ACI per say but rather due to severe malalignment issues in both femurs and both tibias).
Title: Re: Need ACI of Patella insurance help!
Post by: Whibs on September 17, 2012, 04:07:37 PM
Hi

I have been having the same problem my insurance BUPA won't approve this operation, their reason is that is a trial that has ended, but my consultant said he would perform this operation under NHS, so i am on the waiting list.  I hope you can get some help from your consultant.
Title: Re: Need ACI of Patella insurance help!
Post by: ozzie on April 15, 2013, 07:18:17 PM
Hi,  My surgeon, Scott Gillogly, told me (in reference to issues with insurance approval) that he (and others) are soon to publish a new study regarding the success rate of ACI surgery of the patella.  The success rate for the study was 82% and the success rate for Dr. Gillogly was 84%.  His office sent a copy to my insurance, in addition to the Dr. speaking to an MD at the insurance company(apparently peer to peer). 

It may be possible for an individual who needs help getting this surgery approved to request a copy of this article to assist approval.