Our Own Private Hells
Anthem Denied my Knee Surgery. I Fought and Won, but It Still Sucks
One of the worst things about U.S. health care is that if you want to get treatment you often have to fight a multi-billion dollar corporate bureaucracy. On your own.
That’s what I just did. I won. I’m not proud. I’m just furious. Below you can read my appeal of Anthem’s - excuse me, “Elevance’s” - denial of prior authorization to get knee surgery from one of the most respected surgeons in the U.S. Regular readers may recognize a bit of the inimitable Healing and Stealing style.
I’ll try to resist the urge to write too much up front, because the appeal documents speak for themselves. But there are three big picture things worth thinking about. First, this one has all the ingredients of an insurance nightmare. Bureaucrats second-guessing skilled practitioners. Guidelines that force patients into obviously worthless treatments. Claims about patients’ conditions that are laughably easy even for a layperson to rebut. Large amounts of patients’ and medical professionals’ time and money wasted.
Second, U.S. health care forces us all to live in our own private, individual hells. Insurance changes all the time and each wonderfully individualized “product” has its own convoluted appeals process if things go wrong. Look carefully at the bottom of the denial letter. It says “some utilization review services provided by Carelon Medical Benefits Management, Inc., a separate company.” Maybe Anthem screwed you or maybe their “independent” contractor did. Who knows? Then look at the surrender letter - appeal reviews are done by yet a different “independent” company. It’s all designed to leave you naked, confused and alone before the legal power of billions of dollars in capital.
Finally, this isn’t a victory story. A handful of people actually enjoy this kind of fight. For everyone else, a system that requires so many of us to endure the physical, mental, emotional and financial harm from delayed or missed care due to these bureaucratic processes is irrevocably broken. I write about this stuff for a living and it was still terrifying and infuriating. It took me half a day to write and send the appeal (and $8.60 to fax it). Most people without the same resources cancel or delay treatment or wind up in the medical debt meat grinder. The hours and money I lost are gone forever. I’ll never get them back. It’s not a win. Winning would be getting rid of Elevance/Anthem and the rest of the parasitic private insurance industry.
Anyway, here’s the appeal and below it Anthem’s original denial and their surrender letter. I sent the appeal at 6:45 pm after receiving the denial. They rolled by lunch the next day. Dr. Reznik, by the way, is brilliant. The surgery went well - I started putting a little weight on my knee within 24 hours, the pain is pretty mild and I’m off crutches in less than a week. The idea of Anthem second-guessing Dr. Reznik and his amazing team would be funny if not so outrageous. Cheers.
John Canham-Clyne
XXXXXXXXXXXXXXXXX
New Haven CT O6513
203-XXX-XXXX
Member ID: XXXXXXXXXXXXX
Anthem Blue Cross and Blue Shield
Grievances and Appeals
P.O. Box 1038
North Haven, CT 06473-4201
VIA FACSIMILE 1-855-321-3642
July 2, 2024
RE: Appeal of Review Reference number XXXXXXXXXXX
Dear Anthem Grievances and Appeals:
I am in receipt of a letter from Anthem dated June 26, 2024, reference number XXXXXXXXX, denying prior authorization for payment for Dr. Alan Reznik of Connecticut Orthopaedics to perform arthroscopic meniscectomy including debridement/shaving of articular cartilage and removal of loose or foreign bodies on my left knee. The denial was in error. This is an appeal of the denial. Reverse it immediately.
For nearly a year, I have been experiencing moderate pain on the inside of my left knee that has restricted several of my daily activities. Seated, the pain is a constant 1-2 on the 1-10 scale. Walking is a 2-6, depending on the day, the length of time walking and the terrain. My knee also affects other daily activities. Details:
· In recent months knee pain has occasionally interfered with my sleep. If I shift in a way that puts lateral pressure on my left knee, I wake up.
· I can’t run at all.
· I can’t walk for long periods without significant pain.
· I haven’t dared swim. The water’s resistance to lateral movement likely would be excruciating.
· I try to force myself to maintain an even gait, but a slight limp due to knee pain is generating left hip pain.
· I can’t mow our entire lawn because a portion of it is on a hillside and maneuvering the lawn mower puts too much lateral stress on my knee.
· Indeed, walking or even standing on uneven surfaces for any length of time increases the pain.
· I can’t pivot or twist, making some household chores either impossible or much more time-consuming to complete.
I’m an active former competitive athlete. I have serious orthopedic problems with my feet that already limit my ability to engage in vigorous cardiovascular exercise. Left knee pain is further limiting my choices, which in turn threatens my overall health. The muscles around my knee are strong, I just can’t put consistent weight on the joint without pain, and then it’s tolerable only in a straight line. Pivoting or twisting causes more intense pain.
Your letter cites only one reason for the denial: “the notes do not show that your knee grinds, catches or pops.”
Of course my knee grinds when I walk. That’s what meniscal tears and loose material in your knee feel like. The grinding is the source of the pain that is interfering with a host of my daily activities. My knee consistently pops when I walk up and down stairs. I saw Dr. Reznik yesterday. I sat on the edge of the examining table. He asked me to extend my leg. I did so. He asked me to lower it, and when I did, there was an audible “pop.”
There are three other relevant pieces of information that demand payment for this surgery.
1. Dr. Reznik performed identical arthroscopic surgery on my right knee 2 years ago, which my insurer at that time approved and paid for. It was a complete success. My right knee is pain-free and as strong as it has ever been. So I’m familiar with both the symptoms and the procedure. I’m also curious whether your reviewer reviewed my chart and noticed that I’d had this previous surgery.
2. You have already wasted weeks of my time and a significant sum of the plan’s money on absolutely meaningless, ineffective treatment. When I was first examined by Jaclyn Ryan, Dr. Reznik’s physician assistant, who has 30 years’ experience in the field, I was informed that the initial treatment would be a cortisone shot and either physical therapy or a commitment to doing a series of exercises at home to see if they would improve my condition.
It was obvious at the time that this was a hoop to jump through for insurance purposes. Once the anesthetic used with the cortisone wore off, there was no change.
The exercises were the very same routine I had been given during recovery from the previous right knee surgery, which at the time I performed both under the supervision of physical therapists and on my own at home. When I was seen for my left knee, I had already been doing three of the more difficult exercises 3-4 times a week at the gym using additional weight. Indeed, the Christmas after my first surgery I asked for and received as gifts ankle weights and resistance bands for the express purpose of allowing me to do front and back leg lifts and abduction exercises on my own to strengthen my legs and protect my knees. When I informed Dr. Reznik’s office that I was already doing these exercises and that the likelihood of them leading to improvement was thus zero, I was told that it didn’t matter – Anthem will not approve any surgical intervention without first attempting cortisone+exercise.
So for six weeks following an ineffective cortisone shot, I diligently performed all the exercises on the sheet, including the easier ones that are more appropriate for post-surgical recovery, with no change in my symptoms. Throughout the period of this injury, I have been able to ride an exercise bike with minimal pain. I can do isolation resistance exercises on my quads, hamstrings and glutes with minimal pain as long as I pay careful attention to form. My wife tells me I have great legs. I just can’t walk for long periods of time without moderate pain; pivoting or twisting causes sharp pain (even while seated with my feet on the floor if I’m not careful), and; pain occasionally interrupts my sleep.
It's bad enough that your prior authorization decision tools have already forced one of the most respected surgeons in the country to put patients through unnecessary treatment that everyone involved knew would be ineffective. It’s frustrating enough that I had to waste six weeks of wonderful spring weather during which my ability to take walks with my wife was diminished and marred by pain, and that my recovery will be extended through much of the summer, all to meet a rote bureaucratic requirement. It’s absurd that the plan would pay for additional visits to my physician and for a cortisone shot that did nothing, adding additional expense to the ultimate cost of treatment.
That is, if you were actually prepared to pay for my self-evidently medically necessary treatment at all, for which the Town of Hamden, Connecticut and my family pay hefty premiums. For that matter, Anthem won’t actually be paying much of the cost, as those hefty premiums still only buy plans with a net $2,000 deductible and it is the beginning of the new plan year.
3. I’m 62 years old. I expect to be an Anthem subscriber for at least 3 more years and likely beyond depending on the vagaries of employer retirement coverage. Any deterioration in my general health resulting from a decrease in physical activity may well cost the plan more money than would be saved by a denial.
Please reverse this denial and approve payment for my surgery immediately. I have learned from Dr. Reznik’s office that he is scheduled for a peer-to-peer meeting with an Anthem physician. I find it offensive that you are forcing him to waste time that would be much better spent seeing patients. You don’t need that consultation to know that this denial is made in error. Reverse this decision now, cancel the meeting with him and let him do his job.
Three final points:
· I am a health care journalist. I will be publishing your original letter, this appeal and any response from you.
· Please provide me with the name and medical license number of the person who reviewed my case, and any and all of their notes or other communications supporting the decision. I am particularly curious to find out whether the person who reviewed my case is an orthopedic surgeon specializing in knee injuries.
· When will Anthem set up a 21st century online method for patients to appeal denials? According to the letter, I can appeal by calling and complaining over the phone or in a written form via mail or fax. This is an insidious method of putting patients at an administrative and financial disadvantage to a multi-billion-dollar corporation. Phone calls do not generate a paper trail, surface mail is far too slow for time sensitive appeals unless you are willing to pay $26.45 for an overnight USPS letter and health care organizations are pretty much the only people in the country who still have fax machines, so many patients would have to pay a commercial service to fax in a complaint. Your mailing address is a PO Box, so patients cannot even deliver an appeal by hand to an actual office. Please don’t plead “security” – all faxes create image files that are stored in the cloud and are thus vulnerable to malicious online actors. A decade after a massive security breach, I would hope that Anthem’s systems staff and contractors would be capable of creating a user-friendly secure email or web-based complaint process.
Sincerely Yours,
John Canham-Clyne
XXXXXXXXX
New Haven CT 06513
203-XXX-XXXX
XXXXXXXX@gmail.com
CC:
Sean King, Acting Healthcare Advocate, State of Connecticut
Senator Martin J. Looney
Dr. Alan Reznik, Connecticut Orthopaedics
Here’s the denial…
…and Anthem’s abject surrender. Yes, Dr. Reznik didn’t have to Zoom with their doctors.
P.S. The cortisone shot and exercise routine described in the appeal weren’t just required before Anthem would approve surgery. Anthem makes patients jump through that hoop before even approving an MRI. So diagnostic imaging that might confirm the relevant potential effectiveness of cortisone and exercises or surgery isn’t even available to doctors. You just have to take the shot and do your leg lifts for six weeks no matter what.
P.P.S. Healing and Stealing tries to avoid writing how-to-fight advice on these incidents because it’s a never-ending black hole and that kind of journalism ultimately legitimates the idea that the system can be fixed with a few regulatory raps on Anthem’s knuckles. However, we love our readers and there’s no greater relief than having a comrade by your side when you’re alone in a big fight. So if you or a loved one is battling an insurance denial, feel free to reach out if you think it can help.
Next up: What Donald Trump and the GOP Bring to Health Care (spoiler: not much)