THR Prior Auth Insurance THR in US

SethNYC

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Hi all,
I have a question about those with experience getting insurance approval in the US. I work for a large company plan with excellent benefits.
The company uses EVICORE to manage prior authorizations. They list criteria required to meet eligibility for procedure approval. One of the main criteria is the Tonnis level which is from 0-3 (nonarthritis on X-ray to severe arthritis). Technically mine may be a 1 on x ray which is mild early joint space narrowing. This x ray requirement is inexact but often used to decide individual cases. My surgeon stated that due to the full thickness labral tears ,chondral defects and FAI on the MRI along with symptoms consistent with hip replacement candidates that I should be approved although there is no guarantee. My surgery is scheduled for April and they do not submit prior authorization paperwork until 1-2 months before scheduled date. The surgeon could not make any promises that the procedure would be approved. This hospital has a team of people who do the prior authorizations and lots of experience submitting them since they do the most joint replacements in the US.
Any thoughts from those who had similar concerns or experiences? Thanks.
 

djklaugh

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@SethNYC Sigh, all insurance companies have criteria for authorizing surgeries. For elective surgeries which joint replacements are considered to be (as opposed to life saving ones) some insist patients try every "least invasive" (AKA cheapest") treatment options before surgery (such as physical therapy, steroid injections, etc). Your hospital and surgeon's office - especially who ever in those offices handles insurance matters - should know just how to work with this company. Sad to say there is probably not much you yourself can do to help with this.

All my surgeries were done through my HMO (Kaiser Permanente) and, yes, they too have criteria for surgeries. Each of my surgeons knew how to document my particular symptoms, "least invasive" treatment trials, etc so I was fortunate to not run up against any problems with authorization.

I do hope that all will go smoothly for you!. And probably other members here will add their experiences. You can try using the search function here - try "insurance" or "EVICORE"
 

benne68

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This hospital has a team of people who do the prior authorizations and lots of experience submitting them since they do the most joint replacements in the US.
I'm guessing that your hospital is HSS from your last comment. I've had multiple surgeries and other treatments with HSS and have never had an issue get authorization. Their team seems to know how to work around the insurance company "requirements."

Good luck.
 

Elf1

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@SethNYC I had to have prior authorization for both my spine and hip surgeries. Staff at both surgeons offices handled all the paperwork. The Neurosurgeons office did call me once to verify that I had gone through physical therapy and where before they finished the paperwork. Other than that I didn't really have anything to do with helping to get the approvals. I think most of these surgeons/practices have people well versed in getting these authorizations approved. Wishing you the best of luck.
 

Jamie

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The comments above are all right on target. Rest assured if for some reason you are denied the authorization for surgery, you can discuss it with your surgeon and contest the ruling. Most surgeons know how to word things to ensure their patients get the care they need, so please try not to worry about this.
 
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SethNYC

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Thank you for your words of encouragement. I researched the clinical criteria needed for approval from my BC/BS policy and they truly focus on prior non surgical failed treatment,
Classification on x ray and Dr notes. Pre-Covid, my surgeon performed 400-500 TJRs per year so they have probably dealt with similar denials before. Dr told me his most recent insurance issues have been getting CT scan approval the month before surgery. He needs this for the robotic component of the surgery. I will start PT again for a month and take my prescribed NSAID. Other than that, I will be pro-active and be in contact with docto and billing staff as I get closer to the schedule April procedure.
 

subie2021

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Last year my OS mentioned the same thing about the pre op CT, because my Medicare advantage insurance is picky about procedure approvals. But it turned out to be no problem at all. My CT was performed 3 weeks ahead of the THR. Here is how it was titled for the records... Routine CT of the left lower extremity according to Mako protocol.

Something I learned through the whole process was to not hold back on reporting pain levels and negative effects of my bad hip on quality of life. The providers remark on these in your medical record and help provide proof of medical necessity.
So if it hurts, let someone know. When you talk to providers give them insight about how the bad hip prohibits you from being fully effective in daily life etc. No sucking it up and stiff upper lip and minimizing your misery.

Good luck to you. Don't stress out about it. The office staff are experts at all this insurance business.
 

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