Still in Limbo, the denial system

My surgery has been rescheduled for the 2nd time.   Now it's Feb 10.   As I had mentioned before, I am waiting this 'vendor' of the BCBS insurance company to respond to my surgeon's request to appeal their initial denial for authorization of the knee surgery.  This vendor is called TurningPoint Health.  So, I did a little research on this outfit and saw what the requirements were to be a reviewer of "peer to peer" cases like mine.  I'm really just writing all this for myself for reference.  

I found on their website a job listing for a "Clinical Peer to Peer Reviewer" for this company.  (This specific job was for peer to peer evaluator for spine).  I was shocked.  These are the qualifications of someone that represents my insurance company, who must decide on my medical treatment, and is supposedly an 'expert peer' that will evaluate my case with my world renown surgeon who is a specialist in the procedure that I need.  Here are the basic qualifications for a "Clinical Peer to Peer Reviewer" for the TurningPoint Health vendor:

Education, Experience and Licensure: 

• Master's Degree as a Nurse Practitioner or Physician Assistant 

• A Board certification as Primary Care and or Acute Care Nurse Practitioner or Board certification as Physician Assistant; Active State Licensure 

• Minimum of 5 years' experience. 

Un-FN-believeable.   Not a physician.  Not even any specific training in surgery, orthopedics, research, or most importantly, not any specifics related to spine! 

Here's another health company and their peer review requirements:

Acentra Health must have qualified peer reviewers who meet the following federal regulations: Must be a doctor of medicine, osteopathy, dentistry, podiatry, or optometry, or another individual who is authorized under Federal or State law to practice medicine, surgery, osteopathy, dentistry, podiatry, or optometry Have a current state license. Are board-certified.  Active practice means that the physician usually practices (on a routine basis) a minimum of 20 hours per week.

Seems that TurningPoint Health has under qualified peer review compared with industry standards.  They mention "peer reviewers who meet the following federal regulations: Must be a doctor of medicine."  

Further, the American Medical Association (House of Delegates) states:

"... the reviewing P2P physician must have the clinical expertise to treat the medical condition or disease under review and have knowledge of the current, evidence-based clinical guidelines and novel treatments."

It seems to be the law:   § 476.98 Reviewer qualifications and participation. LII Electronic Code of Federal Regulations (e-CFR) Title 42—Public Health.  Subpart C—Review Responsibilities of Quality Improvement Organizations (QIOs)  

42 CFR § 476.98 - Reviewer qualifications and participation. (a) Peer review by physician. (1) Except as provided in paragraph (a)(2) of this section, each person who makes an initial denial determination about services furnished or proposed to be furnished by a licensed doctor of medicine or osteopathy or by a doctor of dentistry must be respectively another licensed doctor of medicine or osteopathy or of dentistry in the QIO area.

In case of a denial, this sure will make my case for an external review or lawsuit pretty strong.  Are you kidding me?  A masters degreed nurse practitioner telling an expert surgeon what he should or should not be doing?  This is f-ing crazy.   

Pool, still in limbo

Did the same pool workout tonight, intervals a little more even.  Good short workout, takes only about 10min.  HR higher tonight.  Stuck closer to my 1 min rest interval.

Pool

6 x 50yd  - 44, 43, 45, 47, 48, 49

Max HR - 164

HR 145 - 152 - 3:15

HR 153 - 163 - 1:00

 It was hard, but short and sweet.  I'm sure I could improve my times with an aggressive flip turn, but I'm only pushing off gingerly due to my knee.

Doesn't look like my surgery will happen on Thurs unless something big happens tomorrow.  The insurance company Drs have failed to timely confirm a meeting with my Dr. and as a result, I will likely lose $300 in a non-refundable airline ticket.   I may have an option to have surgery Mon, 2/3.  So crazy, the way I've been jerked around by this insurance company.  

 

Pool, crazy limbo

Here it is coming up on 2 days before I leave for LA for surgery and it's not going according to plan.  I did finally get back to the pool today amidst a hectic first week of classes where I've arranged to be gone the next 2 weeks from MTSU, but Sewanee is crazy ... huge turnout, biggest ever.  I have to teach 5 hrs without a break on the Tuesday before I leave Wednesday.  

My insurance company rejected authorization for my surgery pending a 'peer to peer' review with my surgeon that took place last Friday.   Generally, physicians are 90% successful in justifying surgery, after asking 2 that I know, one a thoracic and the other an orthopedic.  However, it could very well be denied and then, the cost out of pocket could be in the range price of a new car.  I'm talking $30k.   

I have no doubt that Dr. Saliman can make a convincing clinical case for surgery as he likely has these meetings all the time, but he doesn't have my medical records and doesn't know me and why I specifically am a good candidate for the surgery:  most convincingly that I rehabbed a similar previous surgery completely, demonstrated by elite level athletic performance and no reinjury.  Also, normal BMI.  Plus, the insurance covered it completely last time, and they are only obligated to cover 60% this time.  However, the facility and the anesthesiologist claim independently and may offer more coverage.  I should find out by end of day Monday.  And, here's one more crazy thing.  The person who files insurance and delivers cost estimates for the surgery center I was told she has been out sick since Wednesday.  This is nuts!

After 35 yrs under the TN State BCBS insurance plan, I have never had a claim denied.  Here was the verbiage for the initial denial:  

Denial Reason: Lack of sufficient clinical documentation Your records were carefully reviewed. The request to fix a torn cartilage cushion meniscus in your knee cannot be approved. More information is needed regarding your diagnosis and planned surgery. This needs to include your BMI height-weight measurement. Also surgery to fix the tear works better for those who are less than forty years old. It also works better for patients who are forty to fifty years old and very active. Your records do not show that this is the case for you. Please talk with your doctor about treatment options. A copy of this letter went to your doctor.

Yea, they ask about my BMI and say "your records were carefully reviewed."  I have never heard such a level of absolute bullshit.  For years, I've received the full $250 cash incentive awarded by this same company for, in part, keeping a normal BMI.  And.., hmmm, I'm "not active"???   When I chatted with a phone rep of BCBS, she said the decisions were made by their 'vendor' Turning Point Health.  She would not allow me the contact info for this decision maker (although their number is on their website) and was acting as an intermediary between me and them on the phone.  They said something incredibly stupid and ignorant to her about first trying "conservative treatments" before surgery.  Yea, conservative treatment to mask the pain so as to make my meniscus degenerate and become unrepairable.  Dumbasses.    

So, age being the biggest factor, Saliman has debunked that on his website and two studies state at least an 80% success rate of such repairs over age 60.  Due to my previous rehab experience, I would say I'd be closer to 90%+.  

Studies show, successful repair is obtained up to age 70 years.... age, as an independent factor, should not be considered a contraindication for meniscus repair: https://pmc.ncbi.nlm.nih.gov/articles/PMC9891740/ 

https://www.mdpi.com/2077-0383/12/21/6922

Anyway, the next phone call I get from them could be worth $20K either way.  I'll be pretty out of my mind if I don't find out definitively by tomorrow.  I am fortunate that I can afford to pay it, and there is both internal review appeals, and an external independent review process, and of course litigation.  I think I could compile a slam dunk case for an external review.  

Maybe this is a sign of the times.  

The general Republican MO in regard to healthcare, Big Pharma, the VA, etc… is to privatize, maximize profits at the expense of consumer, usually the sick and elderly.   The first things Trump did when he came into office was to eliminate price controls on pharmaceutical drugs for those on Medicare and Medicaid, freeze hiring for VA, stop all research and information sharing for the National Institute of Health (effectively halting cancer research), and for the CDC (in the midst of a severe bird flu pandemic), and withdrew from the WHO.  War on science and gifts to big pharma, CEOs, stockholders, etc...  

Anyway...

In the pool today, I did my usual interval workout and I was really winded but HR never got above 153.   Of course this is from my highly inaccurate watch.  Only 2:30 over 145.    I wonder if this time away from leg use and sprinting will lower my max HR?  

It was pretty much like the previous:

Pool

6 x 50 yd w/ 70 sec rest - 40, 41, 43, 46, 49, 50

I did feel pretty pumped when I finished.  I am quite light.  140.2 lbs.  Maybe losing muscle mass?  

pool, orthos

I've settled on a short simple interval set.  I can be in and out of the pool in about 15 min, and I can do it everyday if I want.  Using watch is inaccurate for HR but I'll post it anyway.

Pool laps  6x50yd w/ ~1:10 rest - 40.3, 45.9, 45.2, 46.3, 49.2, 50

Max HR - 154 

          HR avg - 128 

HR< 128 - 5:09

HR 128-144 - 6:49

HR 145-152 - 1:15

Not exactly 'running the engine hot' like the anaerobic power of track sprinting... more like a zone 2-3 workout.  

At least I'm not heavy - 141. 3 lbs after workout.

About undertaking this surgery, I'm thinking it's going to be a helluva miserable inconvenience. Crutches to early/mid March.  With my time off and spring break, I'll only have to endure 3 weeks or so of crutches at work.  I'm going to follow Dr. LaPrade's more conservative protocol of 6 weeks non-weight since it worked before.  I asked Justin about it, he said I'm more than welcome to follow a more conservative protocol but he says 50% weight bearing ok.  I asked him why, and he said, 'because my stitches are strong.'  Not worried about the stitches breaking, but what they're holding.  Curiously, his radial tear protocol is more like LaPrade's, 6 weeks, no weight.  So, since I do have a radial tear, that's what I'll follow.  LaPrade's decision to not treat this doesn't bode well for my chances for a complete fix.  He saw the risk and chances of success, and at this stage of his career at age 67, didn't want to deal with it.  Justin however, I feel is at the top of game, only 50, and willing to take on the tough cases.  

surgery

Dr. Justin scheduled me for surgery in 2 weeks, 1/30.  My meeting with him was OK.  He described my injury as a oblique root tear along with other parts of the meniscus.  He noted some wear already on surfaces and couldn't be certain the level of repair he could accomplish 'til he got in there'.  I wouldn't say he was brazenly optimistic, nor roundly pessimistic.  Perhaps a bit aloof.  I do like him, trust him, I like what I've seen from his staff, his prompt scheduling, and his willingness to work with my insurance company to reduce my out of pocket expenses.  He did push the BMAC stem cell treatment which I declined (because I don't think it really works that well and is expensive) and like last time, opted for PRP only.   He also mentioned the MISHA knee device, an internal prosthetic, but I'm pretty opposed to that at this point since it is so new, only FDA approved 4/23.  It would be last resort before a knee replacement.  

The logistical issues involved with doing this in LA, in the W. Hollywood area, are formidable.   I know it will not be at all like it was in Vail at Steadman.  It's basically check in, surgery, and adios.  No PT meetings, just bye-bye.   Followup via zoom.  His post op protocol is far less conservative than LaPrade's.  I'll be flying in Wed, surgery Thurs, home on Friday.  At least I won't need to drive.  One of the worst parts is finding someone to check me out.  They will not release me alone to an Uber.  Roya found someone through her caregiver network that I could hire for $150 to check me out and drive me to the hotel, will be worth it, LA during rush hour.  Good, so I don't have to drive in LA.  I'll checking out of the hotel to the airport shuttle only about 15 hrs after I return to my hotel after surgery.  I'll be glad to get home.  

I remember the trip to Vail, this same time of year, 6 yrs ago, it was truly epic 

 

short intervals in pool

At the pool again today, I tried a short interval workout.  50s.  Found that my bicep heart monitor does not work in the pool swim setting, and when it's activated using another mode, like track or gym cardio, it doesn't consistently connect.  So I use the watch, inaccurate HR but it measures distance and strokes quite well.  I'm not going to put absolute data for this workout but I did 6x50yd w/ 1min rest in 40-48 sec.  Pretty slow considering DIII college swimmers cover this distance in 21-22 sec, with a turn, but they also start from a starting platform.  

Tomorrow is my consult with Dr. S.  I'm really quite nervous about it.  I'm happy to see the fires in LA have spared his office and hospital, Cedars-Sinai.   Still no significant pain in the knee.  Looking back, I think I was biking up the mountain just days, maybe even the next day, after the Oct. '18 meniscus tear.  I think pain is not an adequate indicator of the severity of knee injury.  Meniscus injuries seem to have a great variability in treatment, but it seems to me, to achieve a higher level of athletic function, requires a higher level of treatment expertise.  

Pool

Pool opened today and I was there.  I had the place to myself.    Don't yet know how to structure my workouts so I tried to do something similar to what I do on the track.  I tried intervals of 100m, then a few 50m at the end.  Didn't swim much, 450m I think.  Didn't want to do a lot because it's a new thing.  Probably get sore in the lats.   I did 3x100m and 3x50m.  At the end of my 3rd 100m interval, I did just hit a max HR of 170 for a second.  My HR sensor was not connecting well with my watch so I don't have good HR data.  If I'm reading this right, my best 100m pace was about 1:21 sec,  slowest 1:45 sec.   I'm going to do this more often and see if I can get a routine going.  Don't enjoy it that much because it's upper body oriented, but it's better than nothing.  

Another CVD prognosticator

Another study.  Another possible risk factor indicator:  Triglyceride/HDL ratio.  Here is the study issue paraphrased:

Low-density lipoprotein cholesterol (LDL-C) has been cited as the main responsible factor in CVD. Nonetheless, even when LDL-C is well regulated, mainly with statin therapy, a residual risk for CVD still occurs, and it is attributable to other lipid components, namely triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C). Increased TG and decreased HDL-C levels have been associated with metabolic syndrome (MetS) and CVD, and their ratio, TG/HDL-C, has been proposed as a novel biomarker for predicting the risk of both clinical entities... Inflammation plays a crucial role in the pathogenesis of cardiovascular disease (CVD), as it has been linked with both the initiation and progression of atherosclerosis. HDL-C has been linked to cardioprotective effects via its antioxidant and anti-inflammatory properties.

The above paper cites numerous studies showing the relationship between the TriG/HDL ratio and CVD.  

Looking back at my previous test results, when my LDL reached it's highest, 203 (on the egg diet in '21), my HDL also reached it's highest, 59, while my TriG were low, 73.  That gave me a TriG/ HDL ratio of 1.24. Best it had ever been.  Then 4 months later, I congratulated myself for lowering my LDL to 105.  But, my TriG/HDL ratio actually increased quite a lot:  117/44 = 2.70.   Not terrible, but significantly worse.  

As I had discussed in a previous post, the other metric that serves as a prognosticator for both CVD and stroke is the apolipoprotein B1/A ratio discussed in detail in this study.

possible Drs appointment cancellation/ postponement

Who could have thought my Drs appointment next week with Dr. Saliman on my knee would be affected by an out of control wildfire?  Are you kidding me?  My MRI disc was supposed to arrive Monday but tracking says it's delayed "by weather conditions" although it is in LA.  

Dr. Saliman's office on Sunset Blvd is literally one block away from a level 2 fire evacuation zone.  Level 2 means "get ready."  Level 3 means "go."  

I've been waiting for this appt for 2 weeks but some people in LA have obviously far more serious problems.   Assuming I get a meniscus repair, it will take 18 mo to get back to elite level.  Really not even enough time to get ready for '26 if my surgery is delayed much past Feb or March.  

We're about 36 hrs away from a major winter storm, and for here in the deep south, a "major winter storm" means more than 3-4" of snow.   And, due to gross incompetence at the Chattanooga Capitol Toyota dealer's repair shop, I will be without my 4x4.  After a month and 3 different diagnoses, I was told the truck needed a new transmission and transfer case for $9000.   I called BS, took it to the local transmission shop and it was what I originally thought and told them from day 1.... an electrical short in the wiring.  Cost for a new wiring harness installed:  less than $600.   Unbelievable!

Totally sedentary except for my daily 20 pullups, ab wheel, pushups, and bicycle crunches with ankle weights.   My V02 max is gone.   Pool opens Monday.  

MRI with contrast 2/19

2/6/19 just after my previous knee surgery I went to the ER with a heaviness in my chest, I was worried about a pulmonary embolism or clot.   After D-dimer tested high they recommended a CT chest scan with contrast.  I went down to the hospital and picked up the report and disc of that test today.  The report was very detailed and basically said the word 'normal' about 10x in regard to my heart and coronary arteries.  No mention of blockages.  Not really very informative.  FWIW...  

CV Study - dietary LDL / carb intake

This is an odd one.   Purely an anecdotal case study, but references a cohort study on a subclass of individuals who are “Lean Mass Hyper-Responders” (LMHR):  

A recent cohort study of 548 persons on carbohydrate-restricted diets (CRDs) revealed inverse associations between triglyceride/HDL-C ratio (TG/HDL-C) and LDL-C change, and between BMI and LDL-C change, on CRD. This means leaner persons with lower TG/HDL-C ratios generally exhibit larger increases in LDL-C on CRD. Individuals with a particularly pronounced high LDL-C, high HDL-C, low TG ratio are termed "Lean Mass Hyper-Responders." This report provides a clinical vignette of a patient who exhibits the Lean Mass Hyper-Responder phenotype, with LDL-C as high as 545 mg/dl, despite normal pre-CRD LDL-C of 95 mg/dl and consuming a CRD with a high unsaturated/saturated fat ratio. Coronary CT angiography conducted after 2.5 years of extremely elevated LDL-C reveals no detectable plaque development.

This seems to correspond to the time when I was on the zero carb 'egg diet'. Although I didn't exactly meet the criteria for this phenotype -  LDL-C ≥ 200, HDL-C ≥ 80, and TG ≤ 70 mg/dl, I was close:

March '21 - mean body weight about 138.5 lbs, likely about 9-10% body fat, LDL - 203, HDL -59, TriG - 71.   Never had my HDL been that high at the same time my TriG were that low.   My Trig/HDL was never better.  

The case study "LM" was only in his 20s, but after having a LDL reading as high as 545, after two+ yrs on the diet, angiography showed he had accumulated zero plaque or heart disease.  

Back to square one.  It's all very individual and complex.  

Reviews and discussion

I was reading some online discussion on meniscus repair specialist, Dr. Saliman.  Seems like he is willing to tackle the tough and difficult repairs no one else will.  He has a technique called 'circumferential compression repair' which he wrote a paper on in '13.  

Here is some of the discussion I've read from his recent patients who've had surgery with Saliman in just the past few months:

"I had an extremely complex tear that was repaired by Dr. Saliman on September 5th (I’m 7 weeks post-op today). It required 11 stitches to repair and Dr. Saliman said he had to piece it together “like a puzzle.” I traveled from Virginia to see him after doing a second opinion with him because my local orthopedic doctors could only offer a meniscectomy... My physical therapist is super impressed with how I’m doing given being in a straight leg brace for so long. And after seeing the pics from my arthroscopy, she is also amazed that Dr. Saliman was able to repair my tear so well (she mentioned she had never seen a tear so “wavy” before)."

"He said same thing about my repair, it was “like a puzzle” :)))...   I counted 6 stitches. 

"08/26/24 had my ACL and meniscus repaired by Saliman. He really cares about ur success. Told me 85% chance of success.  He told me my meniscus was one of the worst torn ones he's ever seen ...so longer surgery (2 hrs). High character guy. BS free.  Used BioBrace Graft reinforcement & Regeneten reinforcement grafting to the medial meniscus repair."

I think Saliman is a good choice from what I've read but it won't be cheap.  I'll probably pay several $K out of pocket, but that's ok.  My insurance will still pay 60% (for out of network) and I have a $7200 out of pocket max.   His use of new technology (i.e. MISHA knee system, BioBrace, Regeneten, etc...) demonstrates he is very current, and he shows meticulous attention to detail.  So, I think he might be able to help me.   

Hope the new year brings a new knee.  Will be a long recovery.