Yes, I've seen "SICKO" and now I am living it! Any ideas on how to get a referral for "out-of-plan" treatment from an HMO -- specifically Kaiser Permanente? They only cut and I want NA. Any successful appeals to an HMO denial? Any success using a state insurance commissioner, or small claims court?

I successfully appealed a denial by my HMO two and a half years ago. I think I have posted my letter before, but here it is again:

To Whom It May Concern:

I received a denial of request for coverage (dated February 21) for a procedure I had performed to correct Dupuytren’s Contracture (request #398825). The denial was on the basis that “the requested service was considered experimental treatment.” I would like to contest this denial and, before going through the appeals process, have the physician who made this determination review my objection, and, if denied, explain in writing his rationale.

The procedure to correct my condition was a needle fasciotomy. This is not an experimental treatment, as evidenced by the following:

1) There is a CPT code for this procedure:
Diagnosis: ICD Code 728.6 (Dupuytren’s)
Procedure: CPT Code 26040 (Percutaneous Fasciotomy)
2) Both Blue Cross and Medicare reimburse for this procedure.

While open-hand surgery was certainly an effective option, I selected this procedure in preference to open-hand surgery for four reasons:

1) Dupuytren’s is a chronic disease with approximately a 50% recurrence rate after treatment. The needle procedure can be repeated almost indefinitely while surgery can be repeated once, at most.
2) Recovery periods are drastically different. Open-hand surgery can result in recovery times of over 4 months with extensive therapy (The Indiana Hand Center, which does not do needle fasciotomy, indicates that splinting might be necessary for 6-9 months). Recovery time for needle fasciotomy is less than 14 days. In my case I was driving the next day, using both hands on the computer 3 days after the procedure and returned fully to work 9 days later. My occupation as a dairy consultant demands some level of physical work, including the lifting of 50-lb bags. An extended layoff would severely jeopardize the financial security of my family.
3) As local anesthesia is used, the risks of general anesthesia are avoided.
4) The risk of complications (nerve damage, loss of blood circulation, skin damage, infection, loss of mobility, hematoma, bone loss) during and following surgery has been estimated at 20% (Sibbit and Sibbit, 2001). Complication levels this high have not been reported for needle fasciotomy.


The reasons I selected Dr. Charles Eaton to perform this procedure are many:

1) His certification: He is board certified by the American Board of Surgery, with a certificate of added qualification in surgery of the hand, and is a fellow of the American College of Surgeons.
2) His medical education: He received his medical degree from a top medical school, Washington University in St. Louis, where he was president of his medical school class. He received a hand surgery fellowship at NYU and a hand and microsurgery fellowship at the Microsurgery Research Centre in Melbourne, Australia. He has 20 publications as primary or co-author.
3) His specific training: He was trained in n