insurance headaches

Hi, Yes it still exists. A recent press release shows a commitment to even more patient & doctor support : http://www.genzyme.com/corp/in...-070904.asp#TopOfPage.

I had the ACI procedure denied by Mutual of Omaha last fall, also on the basis that is was experimental surgery. I was able to get approval on the first appeal because of the efforts of my doctor and his assistant. They put together documentation that showed it was an FDA approved procedure and they included extensive information they obtained from Genzyme, the company that cultures the cartilage. In addition, my doctor spent considerable time on the telephone with the insurance company's appeal board physician explaining the technique, its benefits, and why it was the right procedure for me. I believe he also explained that my only alternative was a knee replacement. I am sure the documentation alone would not have been enough for the approval. The fact that my doctor had been through this hassle many times probably helped as well. Ask your doctor if he or she can be of assistance in the appeals process. If they don't already have supporting materials from Genzyme you might pursue that yourself. You should also find out what specializations, if any, the members of your insurance company's appeals board have. If possible, request that an orthopaedic surgeon be included in the appeal, or request an outside review by one. Check your policy to find out what recourse you have within their appeals process before launching into legal action. My experience through six knee procedures over a thirty year period is that they often stonewall just to wear you out so that you will give up on the claim. Good Luck.

I can emphatize with your situation. I am in a similiar one myself. One thing you have going for you is that if the insurance company has truly paid EVERYONE including the surgery, then you have something in your favor. The insurance company is part way commited to the next step or surgery. The harvested cells can only be frozen for approxitmately two years. I have went through the same situation expect my insurance has not paid anyone for harvesting the cartilage. I am in the process of applying for my third and final appeal to the insurance company. Do not give up hope. There seems to be more evidence that supports the surgery than facts we do not support the surgery. One other thing you may want to check and see if the insurance has EVER covered this Carticel surgery. This is an important fact you can give a lawyer if you decide to go that route.