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Author Topic: Does ACI last?  (Read 10233 times)

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Offline MegTX

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Re: Does ACI last?
« Reply #45 on: May 08, 2008, 07:14:29 PM »
CRAP.  Hit the wrong button and erased my whole post.

I'll try and be more brief.

Find out RIGHT NOW if your insurance plan through your employer is self insured or not.  Your HR department has to answer this question, and they will try and give you the runaround.  If you work for a large corporation, there's a good chance that it is.

If you find that it is, you are headed for ERISA Hell, settle in for a long fight, and plan on being part of the fight.  The Genzyme people don't know how to fight when ERISA is involved.  It changes all the rules, the insurance company holds all the cards and they know it.  If I hadn't gotten involved and driven the process and been a royal bitch and a half, I'd have not gotten my denial overturned, and it took several reams of paper sent to Aetna, probably a hundred hours on the phone, and 8 months.  And I've been told that was freakin' fast and that I was freakin' lucky.

If you find that it's not, you are actually in pretty good shape, but you'll still have several levels of appeals to fight through, you just have more tools to fight with, and the Dr.'s team & Genzyme will know the ropes.

Good luck, and let me know if I can help.  I'm still working (as I have time) on getting copies of my letters & resource info up on my website so other people can use my information in fighting their denials.
Lateral Release, Medial "Reef" - '91
{16 years of grinding, pain, swelling and lots of ice}
'scope 7/07 - .7cm2 tibial plateau microfracture, 2.5cm2 grade4 patellar CP debridement
ACI & Fulkerson TTT 2/08 (patella lesion then 4.5cmx3cm)

Offline bsonday

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Re: Does ACI last?
« Reply #46 on: May 09, 2008, 01:51:33 AM »
Hey everyone,

My current occupation is PhD student, and my insurance comes as part of the "Student Health Plan".  Since I go to a pretty small university, I am guessing off the top of my head that we are not self-insured.

Thus, I guess it's just a waiting game with going through the levels of appeal.  I'll let you all know how this goes, but I have to emphasize that the doctor seemed very confident about his staff's ability to win this battle.  Then again, he said that they do lose sometimes.

The doctor called me personally last night (wow!) and explained to me that right after my Tuesday surgery, they sent the letter to my insurance company to get preapproval.  He said that technically, they have 30 days to respond, but that they usually aren't jerks about it and get back to us soon enough with the preliminary, expected denial.

In the meantime, I'm going to start collecting books, movies, papers, and other fun stuff.  I'm sure that at the very least, I'll emerge a wiser man for going through this.

Best,
Ben
Removal of loose bodies (cartilage pieces)--7/2/2007
Lots of rehab (quad strengthening) which didn't help much
Biopsy for ACI, 1.5cm x 1.5cm patellar cartilage lesion found--5/7/2008
Patellar ACI with Fulkerson, slight lateral release (to get under the patella)--7/2/2008
Happiness--Early 2010?

Offline MegTX

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Re: Does ACI last?
« Reply #47 on: May 09, 2008, 02:58:54 AM »
Oh, that's good.  Education plans are almost never self insured.  They cannot be for teachers' plans in most states, so you are probably lucky there.

My doc's crew was confident on mine, too, and I almost got completely screwed because they didn't even understand the difference between an ERISA plan and a standard plan.  I will never trust anyone to drive and coordinate insurance claims and appeals again, so long as I live.  YMMV.

I hope everything goes smoothly for you and that you get it approved quickly and with minimal fuss.
Lateral Release, Medial "Reef" - '91
{16 years of grinding, pain, swelling and lots of ice}
'scope 7/07 - .7cm2 tibial plateau microfracture, 2.5cm2 grade4 patellar CP debridement
ACI & Fulkerson TTT 2/08 (patella lesion then 4.5cmx3cm)

Offline casey2291

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Re: Does ACI last?
« Reply #48 on: May 09, 2008, 03:10:26 AM »
Hi,
I hope you don't have any trouble getting approval for your surgery.  I just wanted to put in my two cents about insurance companies.  Trust your OS's office about what they say about the surgery, but also check, check and double check for yourself both with your insurance company and with carticel before your surgery.  Ultimately, it will be you paying the bill if your insurance company decides not to cough up the money.  My OS's office told me that I was preapproved for ACI and it turns out that my insurance company does not do pre-approvals for any outpatient surgery.  I met all the qualifications and procedure codes that would be submitted, but yet I was not guaranteed that they would pay for the procedure.   
LOA #2 and hardware removal 12/15/08-new cartilage from ACI looks "GOOD"
LOA on left knee 3/18/07
ACI and HTO on left knee 10/22/07
scope of right knee on 6/21/07
microfracture left knee 3/18/05

Offline djs60

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Re: Does ACI last?
« Reply #49 on: May 09, 2008, 06:00:09 PM »
Hi Ben,

I'm amazed that you got a next day arthroscopy with Dr. Coles.  Most surgeons do not have that much flexibility.  It also suggests to me your insurance co is not that difficult to deal with; doesn't seem like they required a pre approval of the arthroscopy, which some insurers so.

With my case (trochlea and patella), my surgeon did not have any trouble with the approval, even though patellar aci is technically not covered by my insurer.  I did not have to do anything - I just got a letter from my insurer letting me know it was approved.

Just curious - did you get an answer from Dr. Coles about how many patellas he has done?

Dan
3/06 left knee arthroscopy - grade IV lateral trochlea defect
chondroplasy & removal of loose bodies
1/07 left knee arthroscopy/cartilage biopsy
4/27/07 left knee trochlea & patella ACI with TTO

Offline bsonday

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Re: Does ACI last?
« Reply #50 on: May 09, 2008, 11:11:14 PM »
Hey everyone,

Thank you thank you thank you for all of the insurance advice.  When I asked Dr. Cole's assistant how many patellar ACI's he has done, I got the answer of "Lots!".  I don't know how many that is, but I will be sure to ask Dr. Cole in my next email to him and post the number here.

My insurance actually does require preapproval for an arthroscopy, but the second my Monday appointment was over, they got on the phone with Aetna and called and called and called until they got through to someone who would give approval for the Tuesday (next day) arthroscopy.  I did nothing except await the "It's official" call and sip a cinco de mayo margarita down the street.

Best,
Ben
Removal of loose bodies (cartilage pieces)--7/2/2007
Lots of rehab (quad strengthening) which didn't help much
Biopsy for ACI, 1.5cm x 1.5cm patellar cartilage lesion found--5/7/2008
Patellar ACI with Fulkerson, slight lateral release (to get under the patella)--7/2/2008
Happiness--Early 2010?

Offline Chondrosoldier

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Re: Does ACI last?
« Reply #51 on: May 12, 2008, 03:33:03 PM »
Just a quick note to add to the previous few posts (not Ben):

Some of the surgeons who do patellas are getting around the patella ICD-9 snafu by simply coding it a trochlea or femoral implant and doing the patella as needed.  This is especially true with multiple lesions.  It all gets billed the same and doesn't cost the surgeon any more.  Worth asking the surgeon as while its not "by the book," this simple step can save their office a big headache as well as yourself.  This doesn't apply to the big names like Cole, Farr, Minas ect; they have enough leverage where insurance companies don't question them.
1997 L Traumatic dislocation/ACL
1997-2001 L recurrent sbuluxation
2001 L TTT Realignment
2006 L Patellar Carticel biopsy/debridement
2006 L Carticel 4cm patellar reimplantation
2007 R Carticel biopsy/debridement
 Insurance Battle
2008 R TTT 4CM Patalla/3CM Trochlea Carticel implant
Happiness!

Offline bsonday

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Re: Does ACI last?
« Reply #52 on: May 14, 2008, 05:52:37 PM »
As promised, here are the answers to my questions that I asked Dr. Cole:

1.  How many patellar ACI's have you done?
Answer:  50 to 75

2.  What should my expectations be about getting back to sports,
specifically, my chances of getting back to them and how long after
ACI surgery?  I used to be Mr. Athlete.  I'm okay with not running
marathons ever again, but beach volleyball (on sand) and ultimate
frisbee (on grass) are two addictions of mine that I am hoping to get
back to.  My patellar lesion is, as you said, about 1.5cm x 1.5 cm, so
perhaps you have some experience with other patients who had athletic
lives and injuries similar to mine.
Answer:  FIRST IS QUALITY OF LIFE WHICH IS ABOUT AN 85% PERCENT SATISFACTION RATE

MOST INCREASE ACTIVITY LEVELS CONSIDERABLY AND MANY FULLY.  CANNOT PREDICT, BUT SATISFACTION RATE OF OUTCOMES STILL REMAINS VERY HIGH WHEN WE LOOK AT OUR PATELLA PATIENTS...POSSIBLY AS GOOD OR BETTER THAN ANY OTHER GROUP
Removal of loose bodies (cartilage pieces)--7/2/2007
Lots of rehab (quad strengthening) which didn't help much
Biopsy for ACI, 1.5cm x 1.5cm patellar cartilage lesion found--5/7/2008
Patellar ACI with Fulkerson, slight lateral release (to get under the patella)--7/2/2008
Happiness--Early 2010?

Offline celinenj03

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Re: Does ACI last?
« Reply #53 on: May 15, 2008, 06:41:21 PM »
Sounds good but is it closer to 50 or 75. I don't know sounds like 25 is a big gap when your talking under 100. But I'm sure he's more than qualified. I'm looking for someone who has done about 100. When I had ACL Recon I went with the OS who did about 10 ACL Recons. a week, every week for over 20 years. He had lots of experience and I understand ACI is more rare, but for me I just wish it was more...

Also, did you find out how those 50 to 75 turned out? Maybe he has a patient list you can call some of those people and speak with them to see how they are doing. Dr. Levy's office offered to provide me with several names for referral.

Terrible Triad - 1/16/06 - Basketball
3/15/06 - Scope/Cleanout of to achieve full ROM
5/3/06 - Surgery-ACL Reconstruction-Allograft
9/12/07 - Large Loose body removed;Grade 4 Lesion on LFC
9/17/08-Microfracture, Lateral Release (all right knee)

Offline djs60

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Re: Does ACI last?
« Reply #54 on: May 16, 2008, 10:53:01 PM »
50 to 75 patellar ACIs strikes me as a lot.  It's not a very common procedure, so I'd speculate there would be very few surgeons who have done more. 

Interestingly, my surgeon told me before my patellar (and trochlear) ACI that he believed it was 85% I would be better, 10% that I would not be much different, and 5% I would be worse.

At this point (12.5 months post-op), I am not yet back to my pre-surgery activity level, but I am optimistic that I will get there (I am a lot better in the last 4 to 6 weeks in terms of tolerating a higher level of activity).

Dan
3/06 left knee arthroscopy - grade IV lateral trochlea defect
chondroplasy & removal of loose bodies
1/07 left knee arthroscopy/cartilage biopsy
4/27/07 left knee trochlea & patella ACI with TTO

jonhark

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Re: Does ACI last?
« Reply #55 on: May 17, 2008, 05:56:16 PM »
I think Dr. Cole's philosposy of doing ADL's w/o pain is the ultimate objective of Carticel. I believe that is what the FDA product claim is as well. Anything else is gravy.

I'm at nine months and have noticed pretty significant improvement over the past 4-6 weeks as well.

My advice is to be real conservative with your rehab until 9-12 months. Around that time you are going to definitely feel much better than pre-op.

Then you can start tinkering with your activities and see if your knee responds well. I fully expect another 15 months of improvement for myself. It is such a long process but definitely worth it in the end. There really is no better alternative to ACI right now.

Also, be really cognizant of your gait. Poor gait can really cause a multitude of other problems throughout the body. You'll have to retrain yourself to walk again.

Your defect is at a really manageable size. Be really careful of your activity level pre-op as that baby will grow if you don't watch out. My doubled in size to 3.8 CM^2 in about six months after microfracture. Anything from 2-4 CM^2 is considered a small to medium size defect and should be easy to get a good result.

I've spoken to Cole and his staff about doing my other knee in about six months. I'm really impressed with their proffesionalism. Your in the hands of easily one of the top 3 ACI docs in the country. You have nothing to worry about if you follow his protocol.

Offline mayme

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Re: Does ACI last?
« Reply #56 on: May 18, 2008, 10:35:53 PM »
jonhark,

Just curious--why are you considering Cole to do your other knee instead of the surgeon who did your first knee?

Thanks,   Mayme