chawkins99

My wife has recently been approved (by a surgeon) to receive new knees due to advanced arthritis. Prior to the procedure, they require an MRI in order to provide a personalized implant.

We have received a letter from eviCore Healthcare saying coverage for the MRI has been denied. Our insurance is with Aetna.

The letter begins:

"MedSolutions Inc. d/b/a eviCore healthcare (eviCore) has been authorized by the Health Plan (Aetna) to review certain services."

So, Aetna have passed on my wife's medical history to eviCore without permission. I thought that was against HIPAA.

FWIW the actual knee replacement has not been denied (yet).

ian-mstm

If Aetna has authorized the communication then, as I understand it, it's not a HIPAA violation. In these circumstances, eviCore acts as a subcontractor and is considered part of your health care team.

Ian

Pulaski

Did your wife get a second opinion. For major surgery, such as knee replacements, I would want to be totally sure than any non-surgical alternatives had been fully explored. If your wife didn't get a second opinion I am not in the least bit surprised that her insurance company did.

Like most arms of the US medical system, surgeons seem all too keen to use a patient's insurance as a cash cow to be milked frequently.

chawkins99

She has been through multiple treatments over several years including physio therapy, exercise programs, meniscus surgery, steroid injections, nerve cauterization. We have been convinced she needed replacement knees for a while but had to go through all of the other treatments first.

The surgeon said the only viable option left was replacement.

petitefrancaise

Have you considered seeing a chiropractor specialising in sport injuries? I have a knee that's been operated on thanks to 2 skiing accidents. Last winter, it started really, really hurting inside the knee during my ski holiday and yet I knew I hadn't done anything to hurt it. I was convinced I was going to have to have more surgery. I went to my amazing chiropractor who diagnosed tight IT band - he worked on that and told me to make sure I rollered my muscles after cycling/rowing/running. It took a few weeks but now it's absolutely fine...

chawkins99

Forgot that one. Yes. She's done the chiropractor stuff as well. She's currently seeing a pain management specialist every other month and is on Tramadol but trying to keep those to a minimum to avoid the addiction issues.

uk_grenada

I suggest that you seriously look at the cost of having knee replacement done in France or Belgium, I know that in Belgium The going rate is around 9,000 pounds but that's inclusive of everything including physio.

Pulaski

There are also likely US-trained surgeons in Mexico and other countries in Latin America offering the same surgery at a fraction of the cost in the US.

petitefrancaise

I have a friend with a company that does exactly this in France. They have contracts with a few insurance companies to bring patients from the USA to France for elective surgeries. They ensure that all staff are english speakers and she ( a doctor) makes sure that any surgical staff they use are excellent. This is their website... I hope I'm not breaking any rules, it just might be interesting for people to have a look.
https://www.france-surgery.com/en/index.php


I had a meniscus repaired surgically when I lived in france and it cost 3k euros total. Cost me nothing but that was the bill.

petitefrancaise

I'm so sorry, it sounds awful. Sounds like the surgery should be done as quickly as possible.
Can't believe the insurance company have refused to pay for the MRI. That's pretty much standard for having any ortho surgery, I would have thought.

I think I'd be stamping my foot on this one.

Pulaski

Under the circumstances, I think that is a spectacularly wrong idiom.

uk_grenada

I think this price list might surprise you, I know patrick, he refuses to change his photo, but he's mid 40's now, highly experienced, amazingly cheap bodywork... His speciality is post weightloss plastics, he is a real exoert at dealing with more difficult stuff.

I know you can get it for the same orice here in the caribbean but he works in a huge university hospital in brussels - know where i'd prefer to be...

Dr. Patrick Dedoncker - Plastisch chirurg - prices

mrken30

It might be worth speaking to the health care provider and check that they put in the correct coding. It seems there are multiple codes for similar health problems, some are covered, some are not.

chawkins99

Update: My wife called Aetna this morning and the MRI has been approved.

Hopefully, we won't have an issue with the actual knee-op.

Steerpike

I think you are right. I used to work for a company that did work for big health plans. We were a 'Business Associate' of the 'Covered Entity' and we had to sign a 'Business Associate Agreement' in order to do that work. The BA has to treat the information with the same care that the Covered Entity must.
https://www.hhs.gov/hipaa/for-profes...ml?language=en