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Author Topic: APPEAL DENIED!  (Read 1810 times)

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Offline Cinammo

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APPEAL DENIED!
« on: March 31, 2006, 03:54:34 PM »
Got the letter yesterday and the appeal was denied by our insurance.  Stating it is listed as one of the codes on the governments no pay list and has not moved to the pay list as of this date.  We have one more step and that is to request a formal review and Dr Coles office will do that.  I'm afraid that the answer will not change.

One thing that confuses me is that our insurance is willing to pay for the scope/surgery and all it's related costs but will not pay for the procedure code 29866, which is the autograft.  They go on to state that if they had allowed this procedure and paid they would have paid $1193 for this procedure code??  I have emailed Dr. Coles office and asked the same question.  We can pay that.  I actually told coles office in the email that we could fork out $5000 the day of surgery.  I really don't know what to do now.  I feel like a bad parent in some ways.


My son's pain is gradually getting worse.  I'm wondering if he should get a cortisone shot now?  He's never had one but I was wondering if it was an option? 
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 Jaci

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Re: APPEAL DENIED!
« Reply #1 on: March 31, 2006, 05:16:46 PM »
Cinammo,

I'm really sorry to hear the appeal has been denied; this has got to be a very trying time for you and your son.

Would you be seeing Dr. Cole for the cortisone injection? I'm asking because cortisone can effect the body's healing mechanism and may not be advisable if there is a possiblility that your son would be having surgery in the near future. It maybe something to check on with Dr. Cole if you were planning to see someone else.

Good luck with the formal review.

Jaci

« Last Edit: March 31, 2006, 07:50:51 PM by Jaci »
10/03 Twist injury
12/03 Menisectomy- tears ACL, MCL, & LCL missed by OS
Arthrofibrosis ROM 38-68
3/04- 4/08 Multiple scar tissue procedures:
6 scopes w/LOA, AIR, LR, chondroplasty, synovectomy, bone spur & plica removal
3 insufflations, many injections
Chronic AF, patella infera, IPCS

Offline blackbeltgirl

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Re: APPEAL DENIED!
« Reply #2 on: March 31, 2006, 07:44:57 PM »
Don't give up yet.  With most insurance companies and policies there are multiple stages of review.  (As I'm dealing with the same thing, I know what you're going through.)  There is the 1st round appeal, where your dr talks to the insurance dr for a peer-to-peer review.  Then a formal review.  Then it goes to an outside reviewer.  And with my policy, if it is still denied, I can appeal it to the plan administrator at my company.

As to what to do now, I'm sure Dr. Cole will advise you.  Ironically, I may have to consider an allograft procedure if I can't get the ACI approved, and my OS doesn't really want to go there.  As to a cortisone shot - they work by reducing swelling, and thereby reducing some of the pressure inside the knee.  It's worth asking, but as Jaci said, don't make the decision without talking to Dr. Cole.

Good luck getting everythingi sorted out.  They say patience is a virtue, but I've become a big fan of the squeaky wheel philosphy, at least when dealing with insurance companies.

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: APPEAL DENIED!
« Reply #3 on: April 01, 2006, 02:48:30 AM »
I am hoping that the formal review is not the last step but it may be.  Your right this is a trying time.  I will just have to hope and pray that this all works out for the best.  If any of you have any other advice please don't hestitate to give it.
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 brattkids

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Re: APPEAL DENIED!
« Reply #4 on: April 01, 2006, 09:55:57 PM »
I am really sorry to hear about the denial- I hate insurance companies. You are in so much pain and they seem to know what is best?? I DONT THINK SO  I will keep you in my prayers that the formal review goes well. I can understand how much pain your son is in- I have been there!!!  >:(

I am sure all OS are different but my OS said that coritsone would make my lesions worse. I would certainly ask Dr. Cole about options as there are other products besides corisone out there that could benefit your son.

Dont give up until the "Fat Lady" sings!!! We are here for you!!

Paulette
4/04 microfracture
5/04 debris removal
8/04 OATS with synthetic plugs
11/04 OATS traditional autograft medial femoral chondyle
05/05 debris removal and OATS assessment
6/05 Cadaver Allograft OATS lateral femoral chondyle
9/05 OATS redone could not save allograft plug
12/2006 2007 and 2008 scop