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.
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.