Re: OK Next Step - Medical Necessity

[Guest guest]

Ken,

During my appeal hearing one of the legal people representing my HMO

told me that it was up to them to determine whether or not it is a

medical necessity. It's their catch 22.

It would probably be better for you to have the referral from an OS

who is supportive of resurfacing for active OA patients. Have them

list the limitations of a THR that you would not have with

resurfacing. Stress quality of life of resurfacing vs tentative or

lack of quality of life with a THR.

Best of luck,

Fred

Dr. Gross, C2K 1/21/04

> Hi Everyone,

>

> I need to get a referral from my primary care phys to get the ball

> rolling. It's for an out of state waiver, which I think is doable

if

> what I am going for is not offered in State and is a medical

> necessity. Searched on here found the question raised a few times

but

> no real responses. My prim care phys has no clue what to put

because

> he found about resurfacing from me. (FYI - through my explaination

> and what he has read he thinks it's great.) Has anyone had any

> sucessful experence with this? I think the biggest hangup is going

to

> be why this is a medical necessity vs a THR. I am sure they will

> counter with something like - you can have a nice 'ole THR right

here

> in MA.

>

> Thanks,

>

> Ken

[Guest guest]

At 08:21 PM 7/27/2004 +0000, you wrote:

>Stress quality of life of resurfacing vs tentative or

>lack of quality of life with a THR.

Or better yet, stress how much more money you are likely to save them with

resurfacing than with THR's, assuming that THR's will wear out faster and

have to be replaced more quickly. If you dislocate a THR, there may be

another surgery and hospital stay involved to reduce the dislocation, and

possible revision to correct the reason it dislocated. In my case, I

pointed out the longevity of the women in my family and stated statistics

for revisions and dislocations as they apply to dysplastic hips, and how

medical costs for other items would likely increase as well, since if I

didn't have a good hip, I would likely be more unhealthy and unfit.

Cindy

C+ 5/25/01 and 6/28/01

[Guest guest]

At 08:21 PM 7/27/2004 +0000, you wrote:

>Stress quality of life of resurfacing vs tentative or

>lack of quality of life with a THR.

Or better yet, stress how much more money you are likely to save them with

resurfacing than with THR's, assuming that THR's will wear out faster and

have to be replaced more quickly. If you dislocate a THR, there may be

another surgery and hospital stay involved to reduce the dislocation, and

possible revision to correct the reason it dislocated. In my case, I

pointed out the longevity of the women in my family and stated statistics

for revisions and dislocations as they apply to dysplastic hips, and how

medical costs for other items would likely increase as well, since if I

didn't have a good hip, I would likely be more unhealthy and unfit.

Cindy

C+ 5/25/01 and 6/28/01