Surgery / insurance @#$ / Rant / Vent /

Jun 1, 18 13:25

Post #1 of 20 (2226 views)

Partly to vent, partly to rant. Am open to another point of view re: the following... Currently having a real negative view of insurance carrier right now.

Teenage son tore his labrum (tissue in shoulder) during spring ice hockey tournament a couple of weeks ago. Ortho’s (2 opinions) recommend surgery given the fact that it’s not going to heal itself; his age; desire to get back to high-level sports and competition; all make it the right decision. Main season for ice hockey (travel club, and HS) is Fall through March; Surgery needs about 6 months for a full recovery (I.e. back on ice w/full contact checking). So important to have surgery now, to get back on ice in Nov.

Insurance needs to approve surgery, and !@#$$%^& doc that grants the approval wants an 8-week PT protocol first, before surgery. That would have him miss the entire season (which will be his last season before college). Peer-peer conversation w/our doc and insurance doc, didn’t budge. Clear to me that they just don’t want to pay.

So, (a) we can wait the 8 weeks, ask for approval, and proceed then. But son loses out on basically the entire season :-(
Anecdotally, we’ve heard insurance will also find a reason after 8 weeks to not approve, or delay further.
Or (b) we can proceed with the surgery but pay for it on our own. Then try to file claim later to recover (Yah good luck with that).

What to do? Open to suggestions here

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 1, 18 13:39

Post #2 of 20 (2202 views)

Does he have a chance of making hockey his career / get a scholarship, or would you be simply indulging his love of the game? I'd have a hard time rolling the dice with what that surgery has to cost if it was just to "play a game"...

Re: Surgery / insurance @#$ / Rant / Vent / [snoots] [ In reply to ]

Jun 1, 18 13:44

Post #3 of 20 (2194 views)

Hockey is his sports passion (he’s also having a hard time watching playoffs, knowing he can’t play right now).

Has a chance at continuing to play at college - scholarship D1 unlikely (unless he takes a year off and does the Jr. circuit, which we and he has ruled out doing). Can possibly make a DIII team and continue to play.

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 1, 18 13:50

Post #4 of 20 (2186 views)

A few years ago, I tore my shoulder labrum falling on ice. My orthopedist (who performed hip labrum surgery on me a couple of years before that) said that he wouldn't recommend surgery. I regained full use within a month or two (couldn't reach a water bottle in my bike jersey back pocket for a while). Your case may be different.

PT could work. Also, PT would help to strengthen the shoulder prior to surgery, making the recovery easier and quicker.

----------------------------------
"Go yell at an M&M"

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 1, 18 14:04

Post #5 of 20 (2158 views)

Not sure that cost is worth it for what is - in spite of his passion - a hobby.

I'd also weigh up surgical outcomes, risk and complications

PT whilst it does not work for your time lines, you may find recovery is shorter if he goes in to surgery stronger and fitter.

I'd want to know what post op PT they'd provide

Though I suspect it's all academic as a) they won't want to pay and b) the 8 weeks of proposed PT are likely to be followed by interminable delay after delay as you argue the toss over surgery. I'd guess there is no way they are going to even discuss surgery prior to an assessment at the end of 8 weeks, so you will have 8 weeks, then assessment, the review, then decision - you could still be discussing this in 4 months.

It would also be interesting to know if they would consider it elective following the PT.

If he finishes PT with an assessment that says he is functional I doubt they would approve it, it would depend o what the restrictions of the policy say but if a clinician writes that he has strength and ROM etc are they really going to approve it?

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 1, 18 14:09

Post #6 of 20 (2153 views)

I don't know about shoulder labrum tears specifically but there does seem to be a lot of evidence coming out over recent years that for various orthopedic injuries that often conservative treatment (i.e. PT and no surgery) has just as good of outcomes as the surgery route first.

If you go to a guy who has a hammer, he's likely to see most problems as a nail.

Re: Surgery / insurance @#$ / Rant / Vent / [Andrewmc] [ In reply to ]

Jun 1, 18 14:28

Post #7 of 20 (2126 views)

Andrewmc wrote:

Not sure that cost is worth it for what is - in spite of his passion - a hobby.
....
Though I suspect it's all academic as a) they won't want to pay ....

That’s the issue for me. Despite the premiums paid in, and being generally healthy/fit, with no medical claims, when you finally could use coverage, CIGNA puts up this massive resistance to doing so. And as you alluded to, they will likely continue to do so. Everything from dragging coverage for the MRI (had to do x-ray first, then wait for it to be only partially informative, etc.) to holding back approval. I get that insurance is a business trying to maximize profits, and minimize costs. As such, it can’t really be in the business to be helpful when needed. But that dynamic just sucks.

So we weigh the costs and decide if it’s worth it. If it were an injury to me preventing SBR, would I do it? Certainly no pro card or career in SBR for me, but a hobby, and I would still want to be able to do the sport at a high-level, and get back to being whole. Haven’t we all also dropped a bunch of coin on some aspect of our sport? Being my kid, it’s easy to want to proceed with the best case recommendation - of surgery; and view this simply as the cost of sport. Although clearly, I may be stretching to reconcile things.

Re: Surgery / insurance @#$ / Rant / Vent / [ThisIsIt] [ In reply to ]

Jun 1, 18 14:43

Post #8 of 20 (2103 views)

Re: the PT/ non-surgical angle, paraphrasing docs on latest studies - For youths that are active in high-contact sports, the non-surgical (but w/PT) approach has shown to lead to greater instasbility long-term; Vs. similar cohort, just older. Apparently as you age, there’s less flexibility, and that works favorably from a perspective of stability. So for his age (17) there’s consensus on doing the surgery.

We spoke about doing PT-only, but the tear will always result in pain preventing the arm from being raised above his head. (Can’t play BBall, his other, but recreation only, sport). Since the arm-raise is not a typically a motion in hockey he could try to brace up, and play — but the ongoing and expected contact will mean the joint will experience ongoing trauma. (He lost an edge, and fell on the ice. Then he popped it back in on the bench, went out and it popped out again on a check against the boards. Pain throughout since the initial fall apparently. Good thing the game ended then... and we iced and had him checked out given his pain). Playing with a tear therefore doesn’t seem like a good idea — and while PT can strengthen surrounding structures, the tear will still be there.

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 1, 18 14:43

Post #9 of 20 (2101 views)

You need to see what outcomes for non surgical treatment are

As poster above said. If all you have is a hammer everything you see is a nail

Surgeons cut, and instances inappropriately and physio can provide good outcomes for many things

It's also not great to undertake unnecessary surgical procedures. Harm may be infrequent but it's a risk with every intervention

I'd not write off the PT

Re: Surgery / insurance @#$ / Rant / Vent / [Andrewmc] [ In reply to ]

Jun 1, 18 15:26

Post #10 of 20 (2065 views)

Yes. We’ve got PT conversations/consults teed up.

Yes too on considering the risks of surgery. It’s a “minor procedure”, only from the perspective of the surgeon. Major for the patient.

Re: Surgery / insurance @#$ / Rant / Vent / [klehner] [ In reply to ]

Jun 1, 18 17:53

Post #11 of 20 (1996 views)

klehner wrote:

A few years ago, I tore my shoulder labrum falling on ice. My orthopedist (who performed hip labrum surgery on me a couple of years before that) said that he wouldn't recommend surgery. I regained full use within a month or two (couldn't reach a water bottle in my bike jersey back pocket for a while). Your case may be different.

PT could work. Also, PT would help to strengthen the shoulder prior to surgery, making the recovery easier and quicker.

The labrum is the primary stabilizer of the glenohumeral joint in younger people. Over 40, the rotator cuff is the primary stabilizer. If your (as in you, a guy over 40) shoulder is stable, the only reason to do surgery is pain- debride the torn portion.

Depends on his future use, but if the boy is 17 and just wants to lift and be active, he should still consider repair.

******************************
If I don't, who will? -Me
It's like being bipolar in opinion is a requirement around here. -TripleThreat

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 1, 18 18:44

Post #12 of 20 (1970 views)

40-Tude wrote:

Hockey is his sports passion (he’s also having a hard time watching playoffs, knowing he can’t play right now).

Has a chance at continuing to play at college - scholarship D1 unlikely (unless he takes a year off and does the Jr. circuit, which we and he has ruled out doing). Can possibly make a DIII team and continue to play.

If he primarily only is going for D3 is not going to make a rats behind of difference if he doesn’t play for a season. He’s going to be doing tryouts anyways and if he’s that good, a year off from games isn’t going to change anything. It actually may help some he can focus on speed and skills. If he’s going to miss the whole season as soon as he can do speed work, he should be knocking that out non-stop.

I had to basically take a year off and a half off end of high school and first year of college because of my knee and then played at Iowa State. Maybe I could have been a bit better if I could play straight through. But when you’re playing travel and college either you got it or you don’t. Missing a year isn’t going to change that.

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 4, 18 6:22

Post #13 of 20 (1734 views)

I know the insurance market is messed up, but I'm going to give you some insight from the insurance companies point of view as I have seen this argument before:

They are paying for the surgery, they have doctors on staff or consulting them along with tons of actuaries. Their information probably shows that eight weeks of PT (which is way cheaper than surgery) would have a chance to fix it, so based on their statistics, that extra cost of going through PT instead of straight to surgery is worth the risk. The two opinions you got are doctors saying that surgery will guarantee the fix because PT may or may not fix it. The docs don't want to say PT and then admit they were wrong. I get it, they are doing their job and they aren't paying for it.

This is a constant argument between the medical community and the insurance companies, doctors don't want insurance companies calling the shots, but when the insurance company is paying for it (and has the statistical data) they get to call the shots.

Sounds terrible but maybe giving your kid a winter off of hockey might not be a bad thing. Also this is a good opportunity to teach him how insurance works. I wish my parents taught me some of this basic stuff growing up rather than learning what a deductible was two months out of college in my real job when I was in the ER with a separated shoulder.

Re: Surgery / insurance @#$ / Rant / Vent / [AndysStrongAle] [ In reply to ]

Jun 4, 18 7:19

Post #14 of 20 (1690 views)

My other guess on that is they want the 2 months of PT because it helps increase the success of the surgery. Which really unless your doctor isn’t that busy is really only one extra month of PT because he won’t be able to get him in that quick anyways.

It’s not uncommon for pre surgical PT to get everything strengthened around it to help with recovery.

Re: Surgery / insurance @#$ / Rant / Vent / [AndysStrongAle] [ In reply to ]

Jun 5, 18 13:42

Post #15 of 20 (1536 views)

... By way of an update, got additional opinions from non-ortho docs on this.

PT's (2) both acknowledged that there would be some benefit from a PT regimen, but that it would really only be a way to manage around a limitation presented by the injury, vs. having a repair done. And given the goal (full functionality of movement + contact sports) having the procedure is recommended. Also, for someone going into surgery that is already fit/healthy, a PT routine to strengthen the area pre-op doesn't make a ton of sense. Also spoke w/athletic trainer we know (that works closely w/baseball), and her view was not being able to raise arm up (w/out pain) was a no-brainer to have fixed.

On the insurance front, yes, insurance can draw on data that support positive outcomes following PT, and re-assessment. The peer/peer discussion our doc w/our insurance was that the right comparison is for patients of his age and activity - so it's an apples/apples comparison. Ultimately, they dynamic for the insurance company is to avoid paying, and/or delay as much as possible and only pay as a last resort.

So, we'll have the kid go into surgery now, we'll cover the cost (costs are known), salvage his season, and make the best of it.

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 5, 18 14:08

Post #16 of 20 (1518 views)

If you're going to pay cash. You may find - as it's ortho and elective - you could travel for it if you wanted to consider it. There are overseas equivalents of HSS in NY that do only elective ortho work. Depends on the cost.

You might also consider travelling domestically depending on the cost

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 5, 18 14:33

Post #17 of 20 (1503 views)

I'm sorry, I misread your OP in that I interpreted it as his injury would heal and be ok without surgery but the surgery would make it better, faster so he could go back to playing... after reading your responses, if it was my son and he was in pain and surgery would alleviate that, I would go for the surgery. That said, I'm Canadian so - while it would take a long time to happen - it would be free...

Hope it works out for him!

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 5, 18 14:38

Post #18 of 20 (1495 views)

40-Tude wrote:

Partly to vent, partly to rant. Am open to another point of view re: the following... Currently having a real negative view of insurance carrier right now.

Teenage son tore his labrum (tissue in shoulder) during spring ice hockey tournament a couple of weeks ago. Ortho’s (2 opinions) recommend surgery given the fact that it’s not going to heal itself; his age; desire to get back to high-level sports and competition; all make it the right decision. Main season for ice hockey (travel club, and HS) is Fall through March; Surgery needs about 6 months for a full recovery (I.e. back on ice w/full contact checking). So important to have surgery now, to get back on ice in Nov.

Insurance needs to approve surgery, and !@#$$%^& doc that grants the approval wants an 8-week PT protocol first, before surgery. That would have him miss the entire season (which will be his last season before college). Peer-peer conversation w/our doc and insurance doc, didn’t budge. Clear to me that they just don’t want to pay.

So, (a) we can wait the 8 weeks, ask for approval, and proceed then. But son loses out on basically the entire season :-(
Anecdotally, we’ve heard insurance will also find a reason after 8 weeks to not approve, or delay further.
Or (b) we can proceed with the surgery but pay for it on our own. Then try to file claim later to recover (Yah good luck with that).

What to do? Open to suggestions here

I had both of my labrums repaired. One I tore as a kid and didn't know until I was using it a lot as a triathlete.(Right) The second I got hit by a car and landed on my arm, tore the labrum. (Left)

I had to sue the insurance to cover the second repair. (Left) They gave me some crap and I got a lawyer and things changed. Suddenly I could have the surgery. Yes, it cost me for the laywer, and yes it took a while, but I had the surgery.

"When the power of love overcomes the love of power the world will know peace." Jimi Hendrix

Re: Surgery / insurance @#$ / Rant / Vent / [Andrewmc] [ In reply to ]

Jun 6, 18 12:30

Post #19 of 20 (1407 views)

Interesting angle re: travel option . . . Reduced costs for the procedure would need to be outweighed by costs of time and travel in order to come out ahead. And we would need to research and get comfortable with the surgeon and his/her practice etc.., I do know of HSS, NY - as I've had them work on my knee, some years ago, but doubt there would be cost savings there. Canada would be easy pitch to my son, as I think they play hockey there :-)

Locally, we feel pretty good w/the network of practitioners, and the surgeon we've got also happens to have played high level hockey back in his day. Staying local means son is home by the afternoon following a morning procedure. He believes he'll be able to go into school the next day - tests/finals week happening here.

Wife and I are grateful that we've got the means to cover this, and enable the kid to not miss out on a season before aging up/out of HS level. Personally, still peeved at Insurance being the obstacle in this situation.

Re: Surgery / insurance @#$ / Rant / Vent / [40-Tude] [ In reply to ]

Jun 6, 18 12:39

Post #20 of 20 (1396 views)

only reason I mentioned it was that years ago I did a piece of work for DePuy ortho on high volume elective surgical centres across europe

they were also doing the same work across the US

These days with knee replacements people are mobilizing day of surgry and discharge is swift, so it is sometimes worth travelling if surgery / travel and accom are less than the local all other things being equal (outcomes)

I know nothing about the shoulder surgery but I am sure that there are high volume units with good outcomes that would welcome cash :)

A risk is a post op problem so there is that, but even locally I bet cash provides you options with different surgeons and facilities

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