My insurance denied paying for a cortisone shot for a torn meniscus

[question everything]

I received a denial letter today, for an office visit from March! The insurance paid, as I did my copay.

The reason: "isn't covered by either Medicare or my plan." So I went to the "exclusion" section which is from 2021 and the first item is: Services considered not reasonable and necessary according to the standard of Original Medicare.

So I went to the Medicare site and they do approve Arthroscopy surgery to repair a torn meniscus but my orthopedist decided to start with a cortisone shot and it helped. So why not approve a cheaper treatment?

Yes, it was an expensive office visit: new patient, X-ray: I am not bone on bone on the knees.. and, of course, the shot.

I am pissed. And, of course, with the blizzard outside and two days before Christmas and then the last week when many take off, not much chance of talking to anyone.

Oh yes, I can appeal, but my first reaction was: had this letter arrived two weeks earlier, I would have looked at other carriers.



P.S. I see that there is Medicare Advantage Open Enrollment from Jan. 1 to March 31. I may look at it. As far as I know mine is Medical Advantage.

[JenniferJuniper]

1. Definitely consider your insurance options

Many Medicare "Advantage" plans can be very restrictive.

[Timewas]

2. Well

I don't know why they would deny that, I have had several different shots for my knees, the ones that help most is what was once called rooster comb. has helped pretty well for a long time now..

Medicare advantage plans are a scam...

[LakeArenal]

3. Same here on rooster shot.

I also have heard advantage plans being scams.

[mahina]

4. I had those too, Synvisc. They are great but torn

Meniscus needs surgery. Op, Medicare “advantage” pulls this…stuff all day. This is why they exist, to squeeze profit out of healthcare services for people like you in 1 million different ways.

All Medicare advantage plans are privatized for profit plans with restrictions just as BS as this. Don’t give them any more of your money. That’s my two bits. Good luck! There are healthcare, navigators, or whatever they call them now that help you pick programs and I would be sure to ask them. What happens if you come in to a non-Medicare advantage program with an existing meniscus tear. I will be pulling for you.

[summer_in_TX]

11. Not all torn meniscuses need surgery.

I consulted with my yoga therapist, who suggested gently massaging the knee cap. I laid off some but not all yoga for a few months. The massage worked amazingly well in promoting healing.

I have no residual pain from the tear. My tear was located more on the side than on the front, which may affect healing.

[mahina]

13. That's terrific.

Wonderful for you!

[NoRethugFriends]

5. Medicare Advantage sucks.

This will not happen with a Medigap plan

[dflprincess]

6. If you're not sure whether or not your current plan is Medicare Advantage,

the easy way to tell is, do you show your government issued Medicare card to providers along with your private (gap) insurer's card or just the private plan's ID? If it's just the private plan, then you have MA.

If you do change plans, check out the networks carefully. MA plans often have very narrow networks and require pre-approval for procedures traditional Medicare does not. Interesting that they've added another enrollment period for the private plans. I wonder how much lobbying money the health insurance companies spent to get that.

And, if you missed it, check out this article from the Strib about the Biden Administration cracking down on deceptive advertising for Medicare Advantage plans:

https://www.startribune.com/biden-administration-proposes-crackdown-on-scam-medicare-ads/600235871/

[question everything]

10. Yes, it is MA but, really, I have not have any trouble visiting any provider

they have many in their network. And until now I did not have any problems.

[moniss]

7. I know someone

who has one of those scam Medicare Advantage plans. He has bad knees, diabetes and high blood pressure and he is constantly having to fight with them over every dime. Another guy I know has the same problems except for the diabetes but he has actual Medicare and he never has to fight. He goes to any doctor etc. he wants. I know another guy who a couple of years ago was diagnosed with cancer. He had actual Medicare and they told him they would cover anywhere in the country he chose to go and it would be the same coverage. Thankfully he has done really well and went to a famous Midwest clinic a couple of states over. Imagine the fight he would have had with those Advantage crooks. Imagine if that did happen and in the middle of figuring out the best course to try and stay alive you have to spend countless hours on the phone fighting with people to try and get rid of the Advantage crooks and get back to real Medicare.

It reminds me of when I called these scammers a couple of years ago to try and dig out info on their "plans". The first thing they wanted was name, address and SS number. I told them I just wanted to ask some questions about the plans. They said they couldn't answer specific questions but they would transfer me to an agent. The agent came on all pushy and demanding the same info. I responded by asking him if these plans are actually separate insurance policies apart from Medicare. He again asked me for my info. I told him he didn't need the info in order to answer basic questions like that. He told me that he was hanging up since I wouldn't give him the info.

All they want to do is run those commercials that make big promises and get your agreement to pay. It probably saves somebody who is perfectly healthy a little bit but if health problems show up you could be screwed big time.

[brewens]

8. One thing I know is if they fire you up with cortisone, they can't operate for six months. I've had

both knees, both hips and both shoulders replaced. No, I wasn't a bull rider.

Keep that in mind if you decide to go for the scope. That is best as soon as possible if you surgeon recommends it.

[question everything]

9. Thank you. No, the orthopedist did not recommend

As a matter of fact I went for a second visit two months later, unhappy, wanting the surgery and he said to wait and, really almost a year later I am fine. Have been walking 1-2 miles outdoors and indoors without any discomfort.

[Bobstandard]

12. Say no to cortisone!

Cortisone reduces inflammation but inhibits healing. The knee is the joint responding best to regenerative treatments using stuff like Plasma Rich Platlets (PRP) and human growth hormone (hGH). Surgeons even perform meniscus transplants with great results.

Beware of surgical interventions that treat a torn meniscus by cutting away part of the torn meniscus. Years ago my torn meniscus was treated by a series of cortisone treatments followed by the surgery I just mentioned. Eventually the meniscus disappeared entirely and arthritis resulted. That was finally fixed by a partial knee replacement that was extremely successful. The surgery was done by a guy who told me he didn’t think he’d be doing he surgery for cases like mine because these new treatments were advancing so rapidly.

The problem with my unasked for advice is the cost. My surgery wasn’t covered by insurance so I decided to sell a bunch of stock out of my meager retirement portfolio. I figured a few more decades of pain free mobility was worth it.

Good luck!

[question everything]

14. Thank you! So far I have been pain free for 9 months

An alternative was a shot of hyaluronic acid which acts as a filler.

I thought that I tore it last December while shoveling a lot of snow. So far we've had a lot of snow that I shovel and so far - fingers crossed - only my left lower back hurts from the twisting..

So, yes, I think that I will hold on any invasion treatment and my orthopedist was not in a rush either.

Thanks, again.

[SlimJimmy]

15. So far so good.

I've been retired for a few months, and have Medicare Part A&B and my FEHB as my gap plan. Everything has been approved and paid so far between one or the other, or both. I'm told that the MA plans are crap, so I'm glad I was able to avoid them.