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Revision PKR to TKR

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sheryl7

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I am left feeling heart broken for you after reading your post:scare: , and the insurance company deeming it not necessary to have tkr. I really hope and pray you win your appeal(s). Hang in there a keep up the good fight:flwrysmile:
 
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davrunner

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Thank you all for your support. It really is a roller coaster first the decision to get the surgery after being told you need it, setting the date and going through all the motions of getting the house ready, preparing anfd freezing food, lining up help for when you get back home. Even had the pre-cert from my primary care and getting everything lined up at work.
I have an appointment next week to talk with the surgeon and get the appeal process going. I was soo ready to be in recovery now and working towards loosing the limp and swollen painful joint. I'll keep everyone up to date as the appeal moves forward. They have 30 days to make a decision after they receive the appeal.
 

Toothfairy

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Good luck with your appeal. I can imagine it must be very unsettling and make you very angry indeed. I really feel for you.
Best wishes,
Toothfairy
 
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Davrunner, that has to be so frustrating. It aggravated me that my insurance said I could only have a shot every 4 months, even though the doctor said I could at 3. I can't imagine them denying my surgery. Hope your appeal goes well!
 

sheryl7

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since when do the insurance companies know more than the doctor.
 

Knitter4444

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Just recently the government plans..Medicare and Tricare want more documentation that other methods have been tried before joint replacements. Orthodoc posted the link. I will look for it in a bit and post it here.

There is a process for this. Follow it with your surgeon. If you are are denied by the monitoring contractor you can request a hearing.

Please go through the appropriate steps and follow them to a t. It may be just a set of X-rays that will prove your need.
 

Knitter4444

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One more thing...the govt sets the standards for the private health insurance sector. Not laws but trends. So what you are experiencing is not just the govt agencies.
 

Jamie

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After 2 days of trying to get through to the second level review I finally got a call back late yesterday afternoon. It seems that Tricare contracts out to a "reviewing" company to make determinations if what my doctor has determined is necessary is appropriate treatment. This supposed "ortho expert" honed in on the fact that I have rhuematoid arthritis as the primary cause of my knee deterioration and determined I haven't been treated aggressively enough for RA and thus the revision is no medically necessary, welcome to healthcare run by the government...
The nurse I talked to said I had two appeals and if both are denied that is it. I asked if she has ever seen a joint replacement go through both appeals and be turned down and the person left with a non funtioning body part. She said all the time.
After a night of "kicking trashcans" I've decided to fight back. I am going to go the Freedom of Information route and asking for the specifics of the contract of the reviewers to see what their qualifications are and also to see if there are any incentives for saving money by "preventing unnecessary procedures". I'll be doing this at the same time I submit my first appeal.
Dave, this is shameful and I applaud your approach to go after them with guns blasting. You can win!!! It has been my experience that tenacity and extreme detail in any responses you prepare who a long, long way to winning these fights. Be organized. Document all your statements. Prepare a tabbed document that is flawless and you'll have the best chance possible to be the idiots you are facing. I know this approach works. I've had to use it myself in a couple of cases unrealited to health care. These government weenies (I can say that because I worked for DoD for 30 years) are in every facet of our systems. Keep the faith!!!!
 

Knitter4444

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It is essential to go through the steps that they have set up. It is very important that everything is done in order in case you need a hearing or else it won't happen. Do it their way with terrific support from your OS. And I would suggest that you look at what your OS has written before it is submitted. Another pair of eyes, especially when it is your body, can be very helpful.
Consider this a team effort instead of feeling like you have to gang up. I know it is so hard and the emotions probably go from fury, anger, sadness and just plain miserable. But do it the way they want it..it should not take long and I bet you will be on the road for recovery..not in the timeframe that you wanted of course.

I would also suggest to anyone who needs a pre authorization to get it before scheduling...the other caveat..and you will see this in all your contracts..pre authorization does not mean that they will pay. Strange isn't it?
 

Knitter4444

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If you go through the Freedom of Information Act and get the info...don't do anything with it..Really..not for now.

I can also almost guarantee that a retired dermatologist or general surgeon has looked at your record. And could be a nurse that just goes through a check list and sees..hmmm..he hasn't done this..nor that.

Save your energy about going behind the scenes. You just need this to move quickly and you don't want to interfere with the process.

Dave..I do this for a living..hang in there and let me know if you need help.
 

kneeper

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You're great Merry.
Your case doesn't fit the "cookie cutter," dav so it probably confused the paper work types. Glad you're not taking no for an answer.
 

Jamie

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Merry, that is absolutely fantastic advice!!! You are SUCH a wonderful resource in these matters.
 

Jamie

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YOU BET!!!!!
 

sheryl7

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Thanks Mary for sharing your knowledge with all of us, and especially Dave at that this crucial time of need.
Dave I hope that following Mary's advice to a T, will indeed get you the help you so need, keep the faith and hang in there:flwrysmile:
 
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davrunner

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Thank you all for the great advice and links.
One of the frustrating things about this insurance BS is that I have tried all the conservative treatments for RA. The Rhuematologist has recommended putting me on humira, which has all those nasty side effects, like more susceptable to tuberculosis and death, and I haven't yet been approved by the insurance.
While I pray that Humira works on the RA I'm sure it won't help this knee. I have the grinding bone on bone noise and pain when it's swollen the size of a grapfruit. Imagine what it will be like when the swelling goes down and there's more contact on the surfaces.
I will definitly be tabbing the letter and supporting documentation.. All in all I've seen two rhuematologists, 4 orthodocs and an infectious diesease specialist besides my primary care physician. believe there may be two volumes to my response....
 
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davrunner

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MerryS,
thank you for your advice and offer to help. I'll let you know if I run into any snags. I have been on the answering side of FOIA requests but this will be the first time I'm on the requesting side.
I'm most interested in where all these requirements come from. I know you can't sue the federal government, but believe the light of day has a sterelizing effect on those that use their positions to impose their will rather than following the letter of the law.
Imagine what it is going to be like when our entire health care system is run this way...
 
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davrunner

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Okay, not sure if it was all the prayers or my OS who talked to the insurance company numerous times, found out today that they have approved the surgery. My new date is Oct 25. Hopefully no more changes...
 
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