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THE APPEAL LETTER TO CIGNA (NAU IS "national appeals unit")
Dear CIGNA NAU:
I have received your written notice, dated Aug. 27, 2004, 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 55-year-old male diagnosed in March of this year with end-stage
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 extremely 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
competitive handball, three to four times a week, and a rigorous regime of
weight-resistance training, and aerobic conditioning. Now the activities that
helped keep me healthy are closed to me.
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
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.
I have a number of acquaintances (a couple of them now-former handball players)
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. This does not seem a
healthy future.
But with the surface arthroplasty I have requested, and you have initially
denied, the activities that helped me restore my health and maintain it after I
quit smoking in 1985 would again be possible for me.
My own condition now is such that I can no longer use equipment like the
StairMaster for aerobic conditioning, and 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 less 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 CIGNA in past cases has agreed to cover the surgical procedure
under the standard code (27130), but 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 CIGNA harmless for
any negative medical implications that might arise from use of the Conserve Plus
Total Resurfacing Hip System.
I have been adjudged to be an ideal candidate for resurfacing arthroplasty by
Dr. Harlan Amstutz, at the Joint Replacement Institute in Los Angeles.
I am informed by the Joint Replacement Institute that AETNA insurance now
considers hip resurfacing arthroplasty to be a covered procedure; as does
Medicare. (Supporting documentation for the Aetna policy is enclosed.)
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.
Your initial denial took three months, during which time, my condition
deteriorated.
While the Conserve Plus Total Resurfacing Hip System remains officially
"investigational”, it is far and away the best option for my condition. 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 2005.
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 CIGNA.
The Joint Replacement Institute has assured me that Dr. Amstutz will be willing
and available for telephone consultation with the review committee.
Supporting documents are included.
Sincerely,
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