History & Letter to insurance company

It's true. I'm getting old.
I can't believe that I had to dig up information from thirteen years ago regarding my knee history. (FYI-hospitals are only required by law to keep records for 10 years!) Luckily, I was able to obtain all of my records; which I thought was impressive given the time frame and the fact that the hospital has changed ownership/management three times!

In order to plea my case for medical necessity with my insurance company, Carticel (Genzyme or US BioServices) reps helped gather all of my information to present to them as a package. I felt a little overwhelmed at all the information but knew that I could do a better job at explaining my history and current symptoms than all of those pieces of paper. So, I decided to write them a letter of explanation.

Many times patients will write a letter similar to this after their request for precertification (pre-determination of medical necessity) of procedure has been denied. I wrote this letter in hopes of gaining approval the first time.

So, for those you you that are interested in my medical history or those who wish to have a format or help with wording or content for your letter, see below.



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Aetna
Medical Review Board
P.O. Box 981106
El Paso, TX 79998-1106



Dear Sir or Madam:

I am writing to provide you a streamlined history of my left knee problems so that I might be of assistance in expediting the review process.

My left knee pain began in July of 1996 after I was a passenger in an MVC. Emergency room x-rays revealed a foreign body. Later that year, after intermittent locking and pain, I was seen by Sandy Bahm, M.D. In April 2007 Dr. Bahm performed an arthroscopy with foreign body removal. At sixteen years of age, not much could slow me down. I continued to be active in sports, running and cheerleading, but in 1998 the pain worsened and prompted me to return to my orthopedic surgeon. At that time Dr. Bahm ordered physical therapy for strengthening and I continued to treat the pain with NSAIDS, rest and ice. After about a month of PT, I had increasing pain with activity; a second arthroscopy was performed with microfracture of my lateral femoral condyle and partial lateral meniscectomy. Post-operatively I was involved in physical therapy but discontinued running and cheerleading per physician’s request. Pain remained at a basal level after that but never returned to a zero.

Again, in 2000, while I was an undergraduate in college, my knee began to grind and lock at times. After a few months of being symptomatic, Victor Ayers, M.D. performed a third arthroscopy. At that time a lateral meniscectomy was performed and “healing” of the lateral femoral condyle was reported to me.

In 2003, I graduated nursing school and began my career as an intensive care nurse. I continued to have intermittent pain that was mostly alleviated with NSAIDS and rest. I have maintained an active lifestyle with low impact activities like cycling and elliptical for cardiovascular health.

In February of this year, after riding a stationary bike at our fitness club, I experienced increased left knee pain. Over the next couple of weeks pain was not alleviated with NSAIDs, ice or rest and worsened with any activity. I saw an orthopedic surgeon (Bruce Prager, M.D.) and had an MRI done. When he suggested surgery, I consulted a personal friend who is a Sports Medicine doctor and he referred me to James Bothwell, M.D. Dr. Bothwell reviewed my MRI and examined my knee in the clinic. On April 9th 2009, Dr. Bothwell performed my fourth arthroscopy (see findings per OP report).

Today, I consider my knee recovered from my most recent arthroscopy but I continue to have significant pain with any physical activity. I am riding a stationary bike and doing strengthening exercises three to four times a week as tolerated. I have pain at times that renders me incapable of concentrating and unable to sleep at night. I continue to take NSAIDS on a regular basis and hydrocodone as needed.

Dr. Bothwell has discussed all of my options with me. He believes that I am a good candidate for surgery and that I will significantly benefit. My healthcare background gives me the ability to completely understand the procedures, benefits and associated risks. I understand that compliance to physician orders and physical therapy regime is pivotal in my recovery and success.

My knee injuries cannot heal on their own and procedures can only be successful if performed concurrently. I have had knee pain for over a decade and I am looking forward to this opportunity for restoration of function and some relief of chronic pain.

Thank you for your time in evaluating my case. Please feel free to contact me with further questions.

Sincerely,