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Author Topic: Two knees affected by this?  (Read 2493 times)

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Offline Cinammo

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Two knees affected by this?
« on: February 03, 2006, 04:10:29 PM »
My son's surgery on his right knee is scheduled for the 10th.  He has been having pain in his left knee for some time and it periodically locks up.  No where as bad as the right knee yet.  Has anyone heard of both joints having cartilage problems that are the same?  This seems odd too me and he's only 16?????????????
My 17 year old son had the OATS procedure on November 29th, 2006.  He has two previous scopes on the right knee and one on the left.

Offline blackbeltgirl

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Re: Two knees affected by this?
« Reply #1 on: February 03, 2006, 04:33:19 PM »
Doesn't your son have OCD?  It's not uncommon to have similar problems on both knees (unless the injury is the result of trauma).  Many of us, once we start this path on the first knee, refuse to let doctors start treating our "good knee" until the first is resolved.  Your son will have to make that decision for himself.

Jessica
ACI was supposed to be 2/21/06.  On 6/29/06 Insurance co said have another scope, and if it still looks good, they'll ok the ACI.
Microfracture Dec 7, 2004
   3cm x 6cm lesion, LFC; 3cm x 1cm lesion, trochlear groove; lateral tibial plateau lesion
2nd degree black belt, tae kwon do (had to stop)

Offline Cinammo

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Re: Two knees affected by this?
« Reply #2 on: February 04, 2006, 10:24:12 AM »
No he does not have OCD.  I know that he'll have to make the decision for himself.  I was just wondering about other experiences.
My 17 year old son had the OATS procedure on November 29th, 2006.  He has two previous scopes on the right knee and one on the left.

Offline blackbeltgirl

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Re: Two knees affected by this?
« Reply #3 on: February 05, 2006, 02:01:15 PM »
Sorry - mixing up people online I guess.

ANyway - my "good knee" has hurt off and on for years.  And I won't let them even take a picture of it until I'm 60, unless i literally can't walk.  I don't want anyone to confirm that something is wrong, and I don't want to start on the treatment merry-go-round.  And for what it's worth - I had my 1st knee surgery at 17, 2nd at 30, and will have my 3rd at 32 - all for the same knee.  I know I did more damage to the left knee my ignoring it for all those years, but since my right knww (good knee) is still completely ignorable, I'm hoping it stays that way till I'm 60.

Good l uck-
Jess
ACI was supposed to be 2/21/06.  On 6/29/06 Insurance co said have another scope, and if it still looks good, they'll ok the ACI.
Microfracture Dec 7, 2004
   3cm x 6cm lesion, LFC; 3cm x 1cm lesion, trochlear groove; lateral tibial plateau lesion
2nd degree black belt, tae kwon do (had to stop)

Offline Cinammo

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Re: Two knees affected by this?
« Reply #4 on: February 05, 2006, 02:40:17 PM »
Thanks for sharing.  It is hard for me to not want to get him help for his knees, including the left but he did tell me that he does not want to see the doctor about it until it gets really bad.  I will respect his wishes.  He was very disappointed when he found out he may not be having the surgery on his right knee on Friday.  Hopefully we will be able to pay for the portion that our insurance will not cover and be able to go ahead with the surgery.
My 17 year old son had the OATS procedure on November 29th, 2006.  He has two previous scopes on the right knee and one on the left.

Offline blackbeltgirl

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Re: Two knees affected by this?
« Reply #5 on: February 05, 2006, 05:55:29 PM »
It may just be a matter of time.  Other than microfracture, getting approval for OATS and ACI is generally very time consuming, and requires at least 1 round of appeals.  YOur surgeon should have explained that.  My ACI will be postponed for the same reason - dealing with the bureaucracy of the insurance industry.  You should have a chat with the OS, and ask what the risks are if you postpone for a short while to deal with the insurance company.  That way you can make an informed decision to delay or to pay out-of-pocket.  My OS wouldn't even call the insurance company for a peer-to-peer review until he sends them a massive file of research and journal articles, to back up his claims.  But he will also request an expedited appeal.  I'm sure your son's OS is following a similar protocol, and it's just a matter of perseverence and patience.

Good luck-
Jess
ACI was supposed to be 2/21/06.  On 6/29/06 Insurance co said have another scope, and if it still looks good, they'll ok the ACI.
Microfracture Dec 7, 2004
   3cm x 6cm lesion, LFC; 3cm x 1cm lesion, trochlear groove; lateral tibial plateau lesion
2nd degree black belt, tae kwon do (had to stop)

Offline Cinammo

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Re: Two knees affected by this?
« Reply #6 on: February 05, 2006, 07:10:19 PM »
Thank you for that information.  Dr. Cole did not discuss or even bring up the fact that this operation might take some time in getting approval from our insurance.  I guess that was part of the reason I was shocked when our insurance company gave the go ahead and then backed out.  So is it the doctor's office that files the appeal or should file the appeal?  What I mean is I know that I can file an appeal but should I obtain all the paperwork from the doctor or should they be the ones sending it in?

I also have the question in to Dr. Coles office about what the consequences of waiting for the surgery, if any.

Thanks again.
My 17 year old son had the OATS procedure on November 29th, 2006.  He has two previous scopes on the right knee and one on the left.

Offline blackbeltgirl

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Re: Two knees affected by this?
« Reply #7 on: February 05, 2006, 11:05:33 PM »
It probably depends on the surgery, your insurance company, and your doctor.  My insurance company told me the fastest method is for the doctor to call in for a peer-to-peer reew.  My OS has just sent a package of research supporting the surgery, and my need for it.  Once it is received by the insurance company he will do the peer-to-peer.  If that fails, I will file a review, and keep on fighting.  But usually the OS will respsond - especially an offic elike Dr. Cole's, where his is some of the research cited to support surgery around the world.

If you don't already know the name of his insurance coordinator, call in and ask.  He/she may become your new best friend, at least until this is resolved.  I've been calling my dr's coordinator about twice a week for a couple of weeks now.  Each time I call, I ask if it's ok if I check back in a few days, doing my best to let her know I need her help and I need her to stay vigilant, and trying to not be too much of a pest.  I'm sure Dr. COle's coordinator will be able to tell you her success rate getting your insurance company to cover the procedure, how long it usually takes, etc.  Have you seen the written denial from the insurance company yet?  That will tell you why they said no, so that you can fight back better.

Good luck.  It will happen.
Jess
ACI was supposed to be 2/21/06.  On 6/29/06 Insurance co said have another scope, and if it still looks good, they'll ok the ACI.
Microfracture Dec 7, 2004
   3cm x 6cm lesion, LFC; 3cm x 1cm lesion, trochlear groove; lateral tibial plateau lesion
2nd degree black belt, tae kwon do (had to stop)

Offline JG

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Re: Two knees affected by this?
« Reply #8 on: February 06, 2006, 02:13:23 AM »
Jess,

So I'm confused, doesn't it cost to grow the chondrocytes at Genzyme?  I would have thought that the whole ACI process would have to be approved before that happens.  If my memory serves me correct, they take the sample during one surgery, send it to Genzyme and 6 weeks later (something like this) implant it into the knee in another surgery.  Granted this is the best case scenario in terms of timeline.  I would have thought that the approval would have to come before you send to Genzyme.

For my allograft mosaicplasty, my insurance was not even called until three days before surgery.  My OS's office did inform me of this. Because it is not a scheduled surgery, they can't even seek approval until the graft becomes available.  Mine was approved no problem...thankfully. 

Cinammo, the cost of my surgery was crazy.  I think the hospital was like $15-18K (23 hour, 2 nurses just for me an 1 other person), the surgeon and assistant was $8k (I had my right knee scoped as well), the grafts were $5-10K a piece (2 hemichondyles).  I paid out of pocket for the anesthesiologists, $1500.  I had allograft not autograft.

Janice
Sept-99 - L knee LR
Aug-02 - L knee LR/menisectomy
Apr-03 - L Knee Mosaicplasty Using Allograft (18 grafts)/LR/debridement/menisectomy; Right Knee menisectomy.
Apr-04 - L Scope - LR/Lysis Adhesions

Offline blackbeltgirl

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Re: Two knees affected by this?
« Reply #9 on: February 06, 2006, 01:21:41 PM »
Janice -

Genzyme does charge to grow the cells, but not to store them.  Like MANY other people, my surgeon took the biopsy when he did the microfracture, so the cells have been up in the lab for over a year.  But we won't grow the cells until insurance approves it.  It takes about 2 weeks to grow the cells, but they can hold them for up to 5 years, so lots of people have the biopsy taken with other surgery, and hope they don't need it.

I'm surprised that a) your OS didn't seek pre-authorization - you don't need to know exactly when the allograft will be available to get the surgery authorized; and b) that you didn't have to go through an appeal to get it approved.  But glad it was stress-free for you.  I'm just playing the  game at the moment, doing my part to convince the insurance company to fix my knee.

Jess
ACI was supposed to be 2/21/06.  On 6/29/06 Insurance co said have another scope, and if it still looks good, they'll ok the ACI.
Microfracture Dec 7, 2004
   3cm x 6cm lesion, LFC; 3cm x 1cm lesion, trochlear groove; lateral tibial plateau lesion
2nd degree black belt, tae kwon do (had to stop)

Offline Cinammo

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Re: Two knees affected by this?
« Reply #10 on: February 06, 2006, 01:38:26 PM »
I am hoping that the insurance coordinator is not the same person I have talked to in the past.  She is lazy.  I had to go to Dr. Coles Administrative assistant to even get this woman to get the ball rolling on trying to even get the authorization.  Hopefully I can continue to work with his assistant because she has been very helpful.

I have not seen the actual denial paperwork.  I sure have the approval paperwork in hand that clearly states that the procedure is approved!  I know that it's not though.  Some nurse in Medical management(at my insurance) must have came back and reviewed this because that's when she called Coles office and stated the procedure was not approved.  The insurance will approve everything else, the scope, the hospital etc...  except the actual autograft procedure >:(  I will appeal this and fight until the end and talking to all of you is going to help me through this so thanks a bunch.
My 17 year old son had the OATS procedure on November 29th, 2006.  He has two previous scopes on the right knee and one on the left.

Offline JG

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Re: Two knees affected by this?
« Reply #11 on: February 06, 2006, 04:50:38 PM »
Jess,

Ahhh, I didn't realize that they didn't charge to store the biopsy.  In terms of my surgery, my surgeon does get pre-authorization, it just turns out that my insurance does pay for my surgery so it was really easy to get it (like a phone call I think).  I am very lucky.  I'm not sure if they pay for ACI.

Janice
Sept-99 - L knee LR
Aug-02 - L knee LR/menisectomy
Apr-03 - L Knee Mosaicplasty Using Allograft (18 grafts)/LR/debridement/menisectomy; Right Knee menisectomy.
Apr-04 - L Scope - LR/Lysis Adhesions