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S E P T E M B E R 2 0 1 4 | O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
John D. Kelly IV, MD
CUTTING REMARKS
Escaping the Insurance Labyrinth
Some days it feels as if there's no way out.
I
love my job. If there's one aspect I could do without,
it's the insurance hassles. In this day and age of
pre-certs and denials, I wish I could just take
care of folks without navigating the gauntlet of
insurance checkpoints in order to get
approved.
'Experimental' procedure
I've been performing hip arthroscopy for
more than 15 years and have helped many patients with this ever-evolving proce-
dure. Yet, some insurers will deny coverage for this technique because they
deem it experimental. Never mind that the patient's hip has a bone spur the size
of Boston or that their labrum is in more pieces than a box of Cracker Jack!
"All non-op measures were not exhausted, including physical therapy,"
insurers will say when explaining a denial, some requiring a whopping 6
months of PT. Great, the labrum is so detached it is in the other room and I
am going to subject my patient to PT and all its inherent twisting and probing
and prodding for 6 months?
Denials are not unique to the hip. I'm lucky to get a biological cartilage knee
resurfacing approved. When I do, I light 3 candles at church and throw a
party. Here again insurers like to bandy about the "experimental procedure"
line. So, the 3cm defect in the 20-year-old knee will respond to copper knee
sleeves and gingko?
To make matters worse, the kneecap is not covered by some insurers, con-
sidered by some as a "non-major weight-bearing area." Last I checked we
humans do, in fact, walk on our legs.
I remember a patient with a knee chondral lesion so large, it had an area
code. The only recourse for him was a biologic, cell-based cartilage trans-
