I called mt Massachusetts BCBS provider member line and they told me that the procedure is not covered. I used information from Eaton Hand Center 'Percutaneous Fasciotomy' but they said they can't find it as an approved procedure. They also don't use the procedure number or diagnosis number system.

They also looked to see if the Hand Center was part of the BCBS provider network and they are not. Maybe this is the reason they don't cover the procedure.

The only advice was to get the procedure done, then apply for special approval after the claim is denied. The support person was very helpful and when she heard the benefits vs. open surgery, wanted to tell her mother about it. So it wasn't the rep. BCBS has no listing of this procedure for coverage.

Has anyone successfully had a BCBS covered NA Procedure? If so, can you send me references that I can use for them to look up?

TIA,
Bob

Bob,

Dr. Eaton's office will gladly give you the code for BCBS. I wonder if your BCBS coverage is HMO or PPO? I have the PPO and went to Dr. Eaton in February. His office did the insurance billing for me and it was just as I expected after speaking with BCBS a few months before the procedure. Dr. Eaton is "out of network" and the cost was $200 for the office visit, and $500 per finger (he worked on 2) making the total bill $1200. BCBS reimbursed me $300. Had I gone to Dr. Eaton's partner Dr. Zidel who is in the BCBS network I would have been reimbursed more.

Bob,

When it comes to such a rarefied specialty as CHS, I'm sure insurance companies take the lead from the doctors, not the other way around. NA is *far* from "usual and customary". It's still *so* off the beaten path that the insurance confusion overwhelms the fact that a procedure has been done at a small *fraction* of the "usual and customary" cost of OS.

But you bring up a good point: We'll know NA has *really* arrived when insurance companies routinely question why a particular case went straight to OS with no previous attempt at NA. It will certainly be in their best interest to do so. Eventually the Light with come on, but that's years and years away. However, the benefits of NA are so powerful, I do believe we will get there.

The following is a slightly edited letter I sent to my insurance company when I successfully appealed their denial of coverage for NA performed by Dr. Eaton.
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. 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 several times, while surgery can be repeated at most once, and often not at all.
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 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 needle fasciotomy by doctors who have been performing this procedure for approximately 30 years.
4) His experience: He has performed nearly 1000 needle fasciotomy procedures; he is also skilled in wrist arthroscopy, replantation, microsurgery, minimally invasive hand surgery, and joint replacement in the hand, and so has extensive knowledge of hand anatomy and function.

To this date, approximately one month after the procedure, I am completely satisfied. My contracture was reduced from 55 degrees to 10 degrees and remains at 10 degrees thus far. I have both pre-operative and post-operative photographs taken by Dr. Eaton, should you be interested.

It should be of additional interest to GHC that open-hand surgery is several times more expensive than needle fasciotomy.

Finally, my appeal is not only for myself, but also for the thousands of people suffering from this debilitating disease – one estimate is that 10% of men over 50 will be affected. They should not be denied effective and minimally invasive treatment because their insurance will not provide coverage.

I am looking forward to your reply.


Sincerely,

I also had my claim denied for NA by Dr. Eaton.

My Healh Care provider has a three level appeals process, Written, internal hearing panel and an external review by three physicians choosen by the State of Delaware (I assume this third level is required by the State).

My initial written response was remarkably similar to Steve's, and was denied. My presentation to the appeals panel, a slick job done with powerpoint slides, photos, comparitive cost tables, etc. was also denied. Having given many presentations, I knew this second level appeal was doomed from the start, just by the panels body language and facial signals. I bet few appeals are approved by such a panel who's living is dependent upon the heathcare provider.

Thank goodness the State requires an external review, and in this third stage of the appeal process 2 of the 3 doctors agreed with me.

Nevertheless, the procedure was only covered at the out of network rate, but still better than having to absorb the full cost. The whole process took about 3 months, and I had to make a formal request for each of the appeal stages.

My suggestion to those who have a claim denied; ask your provider to explain the appeals process, and use the info on this board to help you prepare your appeal.

Also: Don't give up!