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Rod Windle Cover Letter for Insurance
Appeal
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November 9, 2007
HMO Help Center
Department of Managed Health Care
980 9th Street
Sacramento, CA 95814-2725
This cover letter accompanies my application for an
Independent Medical Review (IMR). The core issue in this
case is hip resurfacing (HR) versus total hip replacement (THR).
In this letter I will discuss some of the main issues
relevant to my case. In a second letter I will address some
issues regarding the qualifications of IMR reviewers.
My appeal of Affinity Medical Group’s decision regarding hip
resurfacing surgery was denied by Blue Shield on the
following grounds:
1) “…your medical group has affiliated orthopedic surgical
specialists who can provide your care.”
2) “…there is not specialty agreement that you are a good
candidate for a hip resurfacing procedure…”
3) “…(there is not specialty agreement) that this procedure
would be superior to a total hip replacement.”
4) “…there is no medical documentation leading to the
conclusion that a Blue Shield affiliated specialist cannot
provide the specific medically necessary services that you
require (whether total hip replacement or approved
resurfacing procedure with the Birmingham prosthesis).”
1) It is the opinion of the affiliated surgeon performing HR
within the network (Dr. Huddleston) that I am not a good
candidate for resurfacing (exhibit 1). Dr. Huddleston has
wisely self-selected out of consideration as the surgeon who
performs my resurfacing. Accordingly, there is not an
‘affiliated orthopedic surgical specialist’ who has the
qualifications and the experience to proceed as a HR surgeon
in my case.
2) Exhibits 4,5,6 and 7 are from four separate physicians,
each of whom independently supports my request for
resurfacing. Exhibits 4,5 and 6 contain diagnostic
conclusions and treatment recommendations from orthopedic
surgeons who are hip resurfacing specialists. All three
conclude that I am an excellent candidate for hip
resurfacing. It should be noted that the individual
experience level of each of these specialists (Dr. Sparling
with 120 resurfacings, Dr. Ure with 300 resurfacings, and
Dr. De Smet with 3000 resurfacings) far surpasses the
experience level of the Blue Shield affiliated specialist,
who has completed approximately 15 resurfacings. Exhibit 7
is from my personal physician who, while not a hip
specialist, understands the medical science and the issues
involved.
Specialty agreement does, in fact, exist that I am a good
candidate for hip resurfacing.
3. There is, in fact, specialty agreement that HR is
superior to THR in my case. That is why it has been
recommended by the physicians listed in (2), above.
Evidence of the superiority of hip resurfacing for younger,
athletically active males such as myself is voluminous,
increasing daily, and evident to anyone, lay or
professional, who is up-to-date in the field.
THR is an inferior medical solution in my case as I can
reasonably be expected to outlive a THR, resulting in at
least one difficult and costly revision. Of greater
importance is the fact that a THR will place unacceptable
restrictions on my lifestyle and on my athletic activities.
There will be no restrictions placed on my athletic
activities post-surgery by any of the three surgeons who
have diagnosed my case and who support resurfacing. The
research cited in the exhibits below confirms that ‘no
restriction’ is the majority view, supported by over 90% of
resurfacing surgeons.
A medically “superior” treatment is the one that will help
to create the highest possible quality of life by restoring
health and function. For me, longevity is not the main issue
in determining quality of life. It would be far more
desirable for me to have ten years of future activity free
from medical restrictions than a lifetime with the
limitations a THR would impose.
The superiority of resurfacing can be quantified not only in
terms of quality of life but also in terms of future cost
containment. Medical realities and associated cost savings
include:
· reduced risk of dislocation, resulting in potentially
fewer medical interventions
· conservation of bone stock for future revision (if
necessary) which can be expected to result in a lower-cost,
more satisfactory outcome than revision from a THR
· freedom from medical restrictions will translate into
reduced future medical expenses, as participation in desired
sports and exercise will promote both physical and
psychological wellness.
(exhibits 3,8,9)
Any of the specialists who support resurfacing in my case
can provide detailed additional information to support the
superiority of resurfacing over THR in my particular case.
4) Recent research findings indicate that those who perform
hip resurfacing surgery require substantially more
experience than formerly believed in order to become
proficient. At the present time, the affiliated specialist
does not possess the basic level of experience research
indicates is necessary. Thus, even if the affiliated
specialist believed he would be able to perform HR in my
case, there would be serious questions as to whether he had
enough experience to do so. Accordingly, his decision to
decline to offer HR surgery in my case is appreciated.
(exhibit 10)
It should be noted that exhibits referenced above which
consist of journal or other articles are representative, not
exhaustive, of the topics covered. It is expected that
reviewers will be familiar with the breadth of the
literature and will perform their own review, as necessary,
to bring themselves current.
Thank you for your consideration of my request for an IMR.
Sincerely,
Rod Windle, Ph.D. |
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