Where do I go from here? Long..

[OverandOnward]

Don’t know anything about knee surgery … but some general encouragement …

I know this isn’t very specific - kind of fluffy - but if you will keep hanging in there seeking the help you REALLY need, it will find you. No matter how frustrating things seem on a given day or week, something better will be coming. :yes:

You will get through this, whatever “this” turns out to be. Don’t ever let yourself feel boxed in to only one answer. There is always something more you can explore.

Believe always that this is true.

[red_mares]

[QUOTE=horsegal301;8255720]

My horse is still young enough to the point where I wouldn’t want to lease him out. Unfortunately I don’t have enough money to pay for him to stay in training, but I also haven’t looked into the idea of pasture board yet.

Do this now; your knee & PT is much more important than a horse, especially at your fairly young age.

Called my doctor this morning just to make sure they knew the injection didn’t work. The nurses I talked to asked if I had been taking the steroid pack (???) and I was completely dumbfounded because I wasn’t given a script beyond one for more PT from my doctor. Then they told me I couldn’t get the script for the steroid pack because it had been too long since the injection… and then told me I should be taking NSAIDS every day.

I am so frustrated that all they want me to do is take some sort of drug instead of trying to address the problem.

The drugs DO address the problem. You’ve got a lot of pain & inflammation - NSAIDS are anti-inflammatories. A good PT told me years ago, that NSAIDS work great - if you take them. By that he meant regularly and not randomly.

Immediately after, I called another doctor that came highly recommended by people I work with… only to find out he won’t see me for a second opinion until I’m a year out from surgery. Is this common? I am at work now, on the verge of bawling my eyes out because I can’t get thid situation dealt with.

By all means cry your eyes out. Seriously. I did it many times when I was trying to get my ankle straightened out. In the car on the way home from the doc office was my usual.

BTDT, right now riding should be the least of your worries/concerns. For the surgery you had, 3 months is a long time to be recovering. Finding/fixing what is wrong should be your priority, not riding.

I would recommend Healthboards. There are a lot of messed up people on there with a lot of practical knowledge about various injuries and dealing with doctors. Collectively, they know the best docs because by the time you get to be posting there, you’re pretty messed up & been to a lot of docs.

It took me 5 docs (1 podiatrist, 1 gp, 3 orthos) to find the right one. If one of the guys on this list is remotely local to you, I’d give them a call. (My ortho is on the equivalent ankle list, Best. Decision. Ever.)

[horsegal301]

Small Update

I received a letter from my insurance - they are not overturning their decision to give me more Physical Therapy, despite a letter from my Physical Therapist, Doctor, and me.

They said I’ve “exhausted” my grievance appeal abilities.

While I’m happy I am seeing another doctor in a couple weeks, this is really shattering me right now.

[BasqueMom]

Have you checked with your state insurance board, commission, agency? Think they are another avenue of help with your insurance company who apparently are not providing the services stated in their policy. Worth a shot!

[Bristol_Bay]

[QUOTE=BasqueMom;8269979]
Have you checked with your state insurance board, commission, agency? Think they are another avenue of help with your insurance company who apparently are not providing the services stated in their policy. Worth a shot![/QUOTE]

Yes, this, or the consumer affairs reporter at your local paper or TV station, if you have one. This is a prime example of being insured without being covered. I hope the second doctor helps you get some relief.

[geog272]

I have a totally different health problem, but just wanted to say that sometimes you really need perseverance until you find the right doctor. It took me a year and 5 doctors to get a proper diagnosis (and treatment plan) for my problem. Don’t be afraid to be your own advocate and consider bringing a friend, SO, or parent with you to help you make sure you get your questions answered and voice heard when you are at appointments.

[horsegal301]

[QUOTE=BasqueMom;8269979]
Have you checked with your state insurance board, commission, agency? Think they are another avenue of help with your insurance company who apparently are not providing the services stated in their policy. Worth a shot![/QUOTE]

I just looked into NYS Dep of Insurance and it looks like I can do an external review with them.

I am unsure whether or not it’s better to file with NYS or go through with the external review through anthem. I want to make sure I take the right steps.

I did call my doctor and ask him “what now?!” now that my insurance has denied me again. I also called the insurance company to find someone who can go through line by line why they denied me, when according to their criteria, I meet medical necessity.

Is asking for the reviewer’s notes something I can do? I don’t see why not if it regards me and my appeal, but I sure would love to see what that is.

[OverandOnward]

Have you sent your reasons why you do qualify for the treatment to them, in writing? You need to create a definite and timely paper trail inside the insurance company.

Sometimes it is down to one misguided company employee who is new to the job, or is careless, or never understood in the first place. Pushing back and getting someone else to look at it is sometimes enough to get such a decision corrected, and fairly quickly.

Insurance is heavily regulated, wherever you are. If there is a clear error on their part they do not want to bring unwanted attention to it, they want to fix it. You just have to put your position very clearly in writing, and keep pushing for another individual to take a look at it.

There is a big difference between a dispute on a definite error on the part of the insurance company - you have a good chance of quickly winning on that one - and a difference of opinion on the fine points of what qualifies and what doesn’t. Be clear about which is your case and proceed accordingly. In one case you technically are NOT arguing, you are pointing out an error, and they will agree as soon as the right knowledgeable employee sees it. In the other case, you are arguing and on a completely different track.

[horsegal301]

[QUOTE=OverandOnward;8276718]
Have you sent your reasons why you do qualify for the treatment to them, in writing? You need to create a definite and timely paper trail inside the insurance company.

Sometimes it is down to one misguided company employee who is new to the job, or is careless, or never understood in the first place. Pushing back and getting someone else to look at it is sometimes enough to get such a decision corrected, and fairly quickly.

Insurance is heavily regulated, wherever you are. If there is a clear error on their part they do not want to bring unwanted attention to it, they want to fix it. You just have to put your position very clearly in writing, and keep pushing for another individual to take a look at it.

There is a big difference between a dispute on a definite error on the part of the insurance company - you have a good chance of quickly winning on that one - and a difference of opinion on the fine points of what qualifies and what doesn’t. Be clear about which is your case and proceed accordingly. In one case you technically are NOT arguing, you are pointing out an error, and they will agree as soon as the right knowledgeable employee sees it. In the other case, you are arguing and on a completely different track. :)[/QUOTE]

Yup! In my appeal letter (the first time around) I went through all their points about why it wasn’t medically necessary, but proved that it was. Accompanied by doctor’s notes and a letter from my physical therapist.

I also have one of the HR people at work trying to contact them, but they haven’t responded in a week. I was supposed to get a call back from the person who wrote my denial letter yesterday… surprise, surprise, she never called back.

My doctor is fully behind me in whatever external review process I choose. He is very upset and surprised that the insurance turned me down after writing a letter, so he will do what he can to help… I just can’t get that started until I get all the documents back from the insurance company, which I can’t do until this woman talks to me and makes sure she explains line by line why it was denied again.

I have been writing down the names of everyone I’ve contacted and looking into other options of people who could help me or I could contact. I’ve been able to find a lot of organizations that help with people who have been denied who fall under mental or eating disorders, but not so much for my case - at least not yet.

[horsegal301]

[QUOTE=OverandOnward;8276718]
Have you sent your reasons why you do qualify for the treatment to them, in writing? You need to create a definite and timely paper trail inside the insurance company.

Sometimes it is down to one misguided company employee who is new to the job, or is careless, or never understood in the first place. Pushing back and getting someone else to look at it is sometimes enough to get such a decision corrected, and fairly quickly.

Insurance is heavily regulated, wherever you are. If there is a clear error on their part they do not want to bring unwanted attention to it, they want to fix it. You just have to put your position very clearly in writing, and keep pushing for another individual to take a look at it.

There is a big difference between a dispute on a definite error on the part of the insurance company - you have a good chance of quickly winning on that one - and a difference of opinion on the fine points of what qualifies and what doesn’t. Be clear about which is your case and proceed accordingly. In one case you technically are NOT arguing, you are pointing out an error, and they will agree as soon as the right knowledgeable employee sees it. In the other case, you are arguing and on a completely different track. :)[/QUOTE]

In my appeal letter (the first time around) I went through all their points about why it wasn’t medically necessary and tried to prove that it was. Accompanied by doctor’s notes and a letter from my physical therapist.

I saw another doctor last week and he confirmed that I needed more PT. I have significant muscle atrophy in my left quad muscle that is causing my knee to glide off track and that’s what is supposedly causing the pain I’m experiencing. I mailed out all of my documents for an external review (even more doctor’s notes), so now it’s a sit and wait kind of game…

… since I talked to two different people at Anthem and one told me it would only take 4 days to hear back, and another told me it would take 45 days to hear back about their decision. Fingers crossed.

[AKB]

Don’t be afraid to turn up the heat on the insurance company. Call the state insurance commission. Talk with the attorney general’s office. Google and find out what other people have done to make Anthem cover PT.

[OverandOnward]

[QUOTE=horsegal301;8296329]
In my appeal letter (the first time around) I went through all their points about why it wasn’t medically necessary and tried to prove that it was. Accompanied by doctor’s notes and a letter from my physical therapist.

I saw another doctor last week and he confirmed that I needed more PT. I have significant muscle atrophy in my left quad muscle that is causing my knee to glide off track and that’s what is supposedly causing the pain I’m experiencing. I mailed out all of my documents for an external review (even more doctor’s notes), so now it’s a sit and wait kind of game…

… since I talked to two different people at Anthem and one told me it would only take 4 days to hear back, and another told me it would take 45 days to hear back about their decision. Fingers crossed.[/QUOTE]

Unfortunate that you have to go through this … but carry on!

In all honesty, sometimes an insurance company is NOT deliberately trying to get out of paying a claim. These days it is not a smart thing for them to do. But they have employees who don’t understand these fine points themselves, or the policy details. They aren’t doctors, they are often guessing or comparing apples to oranges. Know this is always a possibility when a decision doesn’t make sense and learn how to make their system work for you.

Just went through this with a completely different type of insurance claim (homeowners). The coverage was black type, the incident could not be disputed as covered … and yet the first adjuster mightily confused herself by looking at newspaper articles about what she thought was a similar issue! She even emailed me jpg’s of these articles!

I called back the next day and talked to another adjuster who fixed this mistake and confirmed coverage. He agreed that that first adjuster was off track and was mystified about her interest in the newspaper articles, which were irrelevant to the claim. Good guy, because he brought in some of the office big guns who somehow locked the favorable coverage decision down so the other adjuster couldn’t make waves again. Got the check paying the claim in full just last week.

[OverandOnward]

Just tumbled to something that you’ve been alluding to, OP, that may explain your insurance company’s reluctance to keep paying …

As mentioned previously, health insurance is heavily regulated and has been for a very long time. (It isn’t just this presidential administration.) So this is a universal, not variable from one policy to another, or from one state to another:

Health insurance pays for recovery. Health insurance does not pay for chronic conditions or disabilities, or anything that isn’t recovering / healing / getting significantly better.

Health insurance pays UNTIL the condition is no longer significantly improving (and how this is determined is specifically spelled out). Many policies then have a period of 10 to 100 days of ‘rehab’ to help the patient transition, and then they are done.

You started this thread (as reflected in the title) with concerns that your knee may not fully recover, that you may be facing a permanent condition. In several subsequent posts you alluded to the same thing. The posters in this thread rallied your approach to one of recovery, but it takes more than the COTH forum to determine that, ultimately.

If PT is not going to help your knee heal much more than it has - that is, return closer to its original, pre-injury condition - then now I understand why your insurance company is stepping back. As said previously, if the company was truly mistaken in denying your claim then that is one thing. But if their grounds for denial are firm, you are in a different reality.

In any future discussions with insurance, you have to make the case that the PT and anything else is assisting recovery, and your doctors have to make that case as well. I assume that is what you are doing with your letter. Doctors will help you as much as they are allowed, but they won’t lie if their medical opinion isn’t that, they have too much at stake. This point is likely to be at the crux of the inside-the-policy / outside-the-policy argument you need to be making.

And now here is the most important thing:

In light of this insurance issue, you need to get the mods to delete this thread. I have no idea if your insurance company is investigating this far, or if they ever will. But don’t put out concerns that you may be dealing with a permanent disability/condition in public, where the company could potentially discover that. That helps justify their denial of further coverage.

Also … if this condition is truly not projected to improve much, your horse question isn’t a question. If that is the case, you need to sell your horse and use the money you now spend for his upkeep for all the out-of-insurance rehab you can. You need to not be on the hook for any vet expenses he may require in future.

If the insurance isn’t paying any more, eat ramen if you have to, move to a smaller place, and put all of your focus on making yourself as well as you can be. This is your chance to do the best for yourself that you can for the rest of your life.

I hope you win the argument with the insurance company. If they decide in your favor then that’s one more step toward your long-term future. Keep on healing!

But if they decide against you, you need to focus on yourself first and defer horses until whenever is the right time for you. You need every resource fully dedicated to your physical adaptation and your future physical capabilities.

Please do away with this thread. All the very best to you, whatever future path you are on. Would love a pm someday to hear how it turned out for you.

[horsegal301]

It was more of a concern of what could happen if they continued to deny me physical therapy… if I got more PT and continued to have the pain and stay the same in terms of strength… and then evolved into the fight with my insurance, who continued to disagree with the people who actually saw my knee in person and saw it improving with physical therapy.

That being said, I received a phone call from the independent reviewer this morning and I was approved for more PT, though I don’t know how many more sessions, but will hopefully see a more positive outcome for my knee in the next couple months.

[OverandOnward]

Excellent news. :):)

Good luck! :yes:

[Carol_Ames]

find a sports medicine doctor/ practice:yes: they tend to be, in my experience more proactive:yes:

[Carol_Ames]

location?

Where are you located?

[FoxyandFritz]

Just a thought but could you try finding a gym that has or done rehab? When I had my knee done at 16 my mom could not afford pt and it was not covered by our province. She instead found a gym that had done a lot of rehab work and it was like pt but a fraction of the cost.

[Clair2014]

Great news about the PT! I know from experience that persistence can really pay off when it comes to the medical community and insurance companies. You have to advocate for your own health! Sometimes it also takes trying a number of different doctors until you find the right one. Also, I’m sure you don’t want to hear this, but going out of network to really good specialist and paying out of pocket can sometimes be worth every penny. Four years ago I traveled out of state and out of network to have a very specialized surgery because my chances of a good recovery were so much better. I worked with the providers and the hospital for discounts and took a personal loan to pay the difference. The comment I got the most from people was “I could never afford to do that”. Well, I couldn’t either but when it came to my health I figured it out. It really sucked and I hated going into that kind of debt but you only get one body…take care of it!

With regard to your horse, if you really love him and owning him is good for you mentally, then do what you can to keep him but lower your costs in any way possible so you can make your health a priority. If selling him makes the most sense, then go that route. Only you can decide but be careful to not get caught up in all of the negative “I can’t” thoughts. There are ways to do what needs to be done. Be persistent and creative. Good luck to you!

[horsegal301]

I’m located in WNY. I haven’t been able to find a useful gym around here – they very much cater to the masses: lots of treadmills and the like, small weightlifting area. If it’s anything to do with rehab, it’s a rehab place that deals with insurance. We have a pretty big medical presence here in WNY, and everything is very much individualized. I don’t think gyms want to be part of the liability that have to do with rehabbing/insurance/healthcare.

Clair - I will say he is a new horse, and kind of a “rebound” in that I bought him because I fell in love with him after I had to retired my old guy (and my best friend) due to some hock problems that could never be resolved (clearly we are secretly linked, because we both have bum legs ), but the same connection/bond is not there as I had with my last horse. He’s still fairly young, so it’s not like I was riding much during the week, but even seeing him once a month to go drop the board check off is depressing. It feels like there’s no connection there and I think that may be in part to the discouraging feeling I get when I think about not being able to ride… but I also don’t know if I’m comparing him to my old horse, who I grew up and attached to, and I don’t think that our connection is anywhere remotely close to that at all. I did get a message about trying sidesaddle - and I have, with my old horse. My current horse is too young to throw a ss on him, otherwise that would have been the first thing I did to try to keep me in the horsey spirit.

That being said, I am just now being notified about the approval from the third party who handles the ortho stuff through my insurance… because I called my insurance. The process of having to seek people out on my own because they don’t do their job to call me back is adding to the frustration. I was only approved for 8 more visits, and I’m really questioning what happens if after that point, if my Physical Therapist says I need more, if I have to restart the whole entire process of appealing over again, because waiting another 2 and a half months for another small handful of sessions really makes me want to cry and sitting here typing this is making me tear up.

Here’s hoping that I hear back from my PT to see when I can start again, because that what I need to get back on track and feel better.