Vicky's Healthnet First Appeal Letter
Note: I copied this almost verbatim from Alan Ray, every single patient that I know of, that has used this letter has won their appeal.
ATTN: Services Appeals and Grievances department
P.O. Box 10348
Van Nuys, CA 91410-0348
I have received a written notice, dated September 19, 2005, from Bay Valley Medical Group denying my initial request for pre-authorization for left hip surface arthroplasty. With this letter and attachments, the request is being re-submitted for further consideration as an appeal of the initial denial.
I am a 48-year-old female diagnosed in March of 2003 with advanced stages of osteoarthritis of the left hip, with “some component of dysplasia”. The result of the condition is that I am unable to engage in the athletic activities that have helped me control hypertension and maintain low blood cholesterol levels (as demonstrated in my past two annual physicals). Despite a high-stress professional position and extremely demanding work schedules, I have managed to maintain my health…with the help of personal trainers 2 – 3 times a week, in both weight training and core strengthening with pilates and staying extremely active with activities such as ballroom dancing and hiking, etc. Now the activities that helped keep me healthy are closed to me and my ability to continue working is compromised.
The physician who provided the initial diagnosis also made clear that, with a Total Hip Replacement, these activities would be closed to me for as long as I live. With that word from him, I set out to find an alternative.
It is clear, from what I have read in the professional literature that, with a Total Hip Replacement, in addition to a high level of surgical and post-operative complications, there is an exceedingly high likelihood of dislocation in even basic activities. I have been informed by Dr. Amstutz at JRI that my degree of flexibility makes my risk of dislocation with a THR even greater then the average since I am extremely flexible. This makes me not as favorable for a THR.
It is also clear that, should I attempt to return to the activities that have helped me maintain my health, there is a very great likelihood of dislocation, and a resulting need for a "revision."
From the medical literature I have read, from the research into surface arthroplasty in Europe, and from the anecdotal reports of hundreds of patients who have undergone the resurfacing procedure, both here and abroad, it is apparent that the risks of dislocation and incidence of revision are far lower than with a Total Hip Replacement and makes me a more likely candidate for this procedure rather than a THR..
I have a number of acquaintances as well as family who have had Total Hip Replacements. One of them dislocates his hip when he sneezes. None is allowed to raise his knees to his chest. My Mother can not cross her legs and is forced to sit in an unladylike position. This does not seem a healthy future or desirable for a single 48 year old female.
But with the surface arthroplasty I have requested, and you have initially denied, the activities that helped me restore my health and maintain it would again be possible for me.
My own condition now is such that I can no longer use equipment like the stairmaster or treadmill for aerobic conditioning, and it is getting harder to even use a stationary bike and I can no longer work out with free weights, because the damaged hip will not support the added vertical weight stress. This creates another concern, and that is the loss of bone density, since stress shielding has been demonstrated as factor in the loss of bone density (I believe the applicable consideration is called "Wolf's law").
This risk would be largely alleviated with hip surface arthroplasty, but not with a Total Hip Replacement. The mechanics of a Total Hip Replacement make stress shielding and increased subsequent bone loss more likely, if not inevitable. A Metal-on-Metal resurface arthroplasty, on the other hand, would restore the weight bearing capacity to the hip, allowing some restorative function of weight resistance training, and thereby improving the quality of the bone stock in the operated leg.
It may be inevitable in my life that a total hip replacement is needed eventually. But I think it’s a little early for essentially amputating my hip. Especially when a less extreme option exists. A resurface arthroplasty would allow me to return to the activities that have kept me in excellent health; and, should there come a time when a Total Hip Replacement would be necessary, leave enough femoral bone stock to make the procedure fairly routine. I understand that is not the case when a revision is necessary after a Total Hip Replacement.
I am aware that Healthnet in past cases has agreed to cover the surgical procedure under the standard code (27130), and has stated that they determined the procedure to be non investigational, but will not cover the resurfacing device itself. Since it has been done in other cases, I would presume it is possible in mine, and I would be willing to accept such an arrangement, holding Healthnet harmless for any negative medical implications that might arise from use of the BHR device.
I have been adjudged to be an ideal candidate for resurfacing arthroplasty by Dr. Harlan Amstutz, at the Joint Replacement Institute in Los Angeles as well as Dr. Koen DeSmet in Belgium and Dr, Vijay Bose in India AETNA insurance now considers hip resurfacing arthroplasty to be a covered procedure; as does Medicare. (Supporting documentation for the Aetna policy is enclosed.)
I have compiled a list of other providers that have approved this procedure in the US and many have approved the procedure to be done abroad by an experienced surgeon.
I understand your normal appeal process can take up to 30 days. But I would ask somewhat quicker consideration. I am in unrelenting pain, with diminishing mobility, and I think I’ve waited for longer than a reasonable person might. My condition is rapidly deteriorating.
While the BHR Total Resurfacing Hip System remains officially "investigational”, it is far and away the best option for my condition and is the device closest to getting FDA approval, see below.
On September 8th, the Orthopaedic and Rehabilitation Devices Panel made a recommendation to the Food and Drug Administration (FDA) on the approvability of the Smith and Nephew Birmingham Hip Resurfacing (BHR) System, P040033 for a hip joint metal/metal semi-constrained resurfacing hybrid prosthesis (cemented femoral component and uncemented acetabular component) intended to relieve hip pain and improve hip function in patients who have adequate bone stock and are at risk of requiring more than one hip joint replacement over their lifetimes. I have attached the supporting document for this as well. Hip surface arthroplasty's use is unquestioned in Canada and the UK; it has been used thousands of times in Europe; and approval by the FDA may be as near as the first quarter of 2006.
Your approval of the resurface arthroplasty appears to be my best hope of navigating some of the most physically challenging years of my life with the greatest chance of maintaining my health. And, I would think, in the long term, reducing the costs to Healthnet.
Since there are no doctors currently trained to use this device in the United States I have tentatively scheduled my surgery for December 1, 2005 with Dr. Vijay Bose in India. He has currently performed over 400 of these procedures and was trained in Birmingham, U.K. working closely with the inventors of the BHR device.
I have attached detailed background on Dr. Bose. All supporting documents are included.
HIP RESURFACING VS. THR ARTHROPLASTY
Based on the extensive research I have done on metal-metal hip resurfacing, I am convinced it is the procedure of choice for someone of my age and activity level. Here are the primary advantages I have found:
The femoral head and neck are preserved—which permits standard THR arthroplasty if required at a later date (versus revision THA as would be required following an initial standard THR arthroplasty)
The femoral canal is not exposed—which means far less fat and marrow is released into the bloodstream, thus reducing the likelihood of deep vein thrombosis
Stress loads are distributed to the femur much more normally—which reduces the risk of stress shielding problems as well as the thigh pain that some standard THR arthroplasty patients experience
The larger diameter of the device provides greater stability and range of motion—which results in a significantly reduced risk of dislocation.
The lower wear rate of metal-on-metal increases bearing life—which reduces the need for future revisions
There are significantly fewer wear particles—which reduces the risk of periprosthetic osteolysis and attendant aseptic loosening of the device
While it is difficult to overstate the importance of any one of these advantages, two of them are particularly significant.
First, if a patient has undergone hip resurfacing, it is far easier to convert the patient’s hip to a THR than it would be to revise a standard THR. Also, the greatly reduced risk of dislocation associated with hip resurfacing means far less money is spent reducing dislocated joints as compared to standard THR arthroplasty.