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Old 08-15-2011, 06:32 PM   #1
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Insurance Denial for Talar Allo/autografts for OCD

Hello HealthBoards,

I'm a new poster here, though I've been combing through the posts on this board trying to find some advice, but I figure it might be more helpful to post this to a new thread.

I am a 24-year-old with a five-year-old lesion on my medial talus. It's a relatively large lesion: about 2cmx1.5cmx1cm. I had a procedure using microdrilling and arthroscopy in January 2007. After five years, the pain is back and--if it's possible--it hurts worse than before. I spent a lot of time researching this condition and saw several doctors, all of whom recommended OATS or a talar allograft. I took a leave from my job to have the procedure done, not knowing that instead of the three months I expected to be away, I would be gone indefinitely.

I have a great surgeon who has performed bulk talar allografts numerous times, with great success. But my insurance provider, First Choice Health Network, has deemed it investigational and experimental, as other companies have done for other members of these sites.

I've read many of the stories on here about fighting with insurance companies, but many seem to be a few years old. According to the coding professional at my doctor's office, many of the insurance companies have only recently updated their plan language to specifically deem allografts of the talus investigational. So whereas my doctor's office was able to squeeze the procedure by insurance companies when there was no specific exclusions, now many companies have language to prevent a loophole. And people like me are SOL.

So I'm wondering if anyone here has had any success getting OATS or allografts approved by their insurance carriers. If so, which companies covered it? How did you go about getting them approved, if you had to appeal? I've been speaking with a lawyer and it seems like a good bet would be finding a company that has a history of approving the procedure and purchasing an individual plan out of pocket. It might be cheaper than paying legal fees and risking a law suit.

I'd love any advice, stories, or words of encouragement. I'm sure anyone who has had this condition understands how frustrating this is. The pain is getting unbearable.

Thank you so much,

Olivia B.

 
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Old 08-17-2011, 05:50 PM   #2
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Re: Insurance Denial for Talar Allo/autografts for OCD

Olivia,
Ok I dug up piles of info That I used to successfully win my approval in 2008.
This can possable lead to some very long posts. First have you enquired to get a -- Technology assesment on experimental invetigational or unproven services -- report from your insurer. It will spell out what things they require for the item to be considered, examples...well conducted cohort studies .....randomized controlled trails.......there is significant evidence to conclude that even unproven the service has significant potential as a treatment for that condition or sickness.
Also have you applied for pre determination..this is not preapproval and it is different language and if you call and ask for that and also with what you need to get to make the determination happen. Ask for the above report. Make sure they do not give you the same case numbers as the preapproval for that.. sometimes they just add some letters to the number but it it the same case.
Once you get a report I can get some of the studies I used which all showed good percentage of success, and along with their wording you can submitt that. You can aslo write a letter and compare the cost of the surgery compared to the cost of not being able to walk on that leg.
The thing I did not realize also is the surgeon will charge different from hospital, so while the whole bill may be 35,000 the hospital is charging most of that. My surgeon only charged a bit over 6000 for the OATS....then after a year long fight the insurance gave him a settlement of just over 2000..I was shocked. I spent all that trouble with them for 2000 ( spit in the ocean to them) not that I could have afforded it but still. So even if they do deny in the end Maybe Doc would be willing to drop his fee knowing he would not get it anyhow.

I have some free time tomorrow and will starting to go thru the studies I have.
Diane

 
Old 08-18-2011, 08:28 AM   #3
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Re: Insurance Denial for Talar Allo/autografts for OCD

Olivia,

My insurance company, BC/BS did say back in '08 that OATS for ankle was investigational. We still got it approved. I faxed over paperwork from other BC/BS sites that said it was a medically necessary procedure. My dr. wrote a note, I wrote a note stating how my life was forever changed if I didn't have the procedure. I faxed over all my notes.
They denied the first couple of times, but I ultimately asked for a peer review and it was approved. I didn't let up. I called daily, got names of who I talked to, got the info to them when they needed it. THey paid and approved a 3 night stay in the hospital.

THey are betting that most of the time when they deny it that no one will fight it.

 
Old 08-22-2011, 03:37 PM   #4
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Re: Insurance Denial for Talar Allo/autografts for OCD

Olivia, I haven't had to fight an insurance company for procedure coverage. (Right now the two PPOs I had in July are "negotiating" who was primary and who was secondary for my surgery.)

But was thinking that in theory you should ask them what they recommend as the appropriate treatment if they won't cover OATS or allograft. I can't imagine they would say total ankle replacement is more effective and less expensive than OATS. In my opinion they should be required to recommend an alternative treatment and prove why it's more effective than OATS for your condition.

However, in real life, maybe they aren't required to offer another alternative that's proven effective. Not even sure if they're required to be logical about your health; they're certainly going to be logical about maximizing their profits. Maybe they'll offer to pay for fusion or another microfracture instead. Or maybe they are hoping if they stall, eventually you'll change insurers and not be their headache any more.

In any case, I would say follow the advice of those here who successfully appealed to get coverage and get it approved. In some states, if they deny your appeal, you can appeal to the agency that regulates health insurance. A last resort is to take your case to the news media. When a reporter calls and says, "It is true you're denying treatment for a medically necessary procedure, and without it, the doctor says Olivia will be confined to a wheelchair for the rest of her life?" then the insurance company will suddenly find a reason to reconsider your case. Though of course their first response is usually, "Due to patient privacy laws, we cannot comment on the details of any specific case."

 
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allograft, insurance, oats, osteochondritis dissecans, talus



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