“Not deemed medically necessary”

Some people spend lots of time doing fun things like playing football, or listening to music, or even writing in blogs, but we have entered into that newest form of recreation called, “Ante Up.”  It involves trying to get your health insurance company to cover your accident expenses at the highest possible rate.

We think that we will eventually be on a first name basis with at least 60% of the friendly customer service representatives at our local Blue Cross Blue Shield call center.  Today, Scott had the opportunity to talk with one of those fine folks about Blue Cross’ determination on one of the claims pertinent to his recent ski accident.

When his flesh experienced a severe and unplanned impact with one of the slopes at Breckenridge, his left hip was dislocated.  The ball was thrust backward out of the socket, fracturing the socket.  Scott was knocked unconscious by the fall, but once he had been stabilized and had taken a rather pricey ride (of which he has no memory) in an ambulance to the Summit County Medical Center, he came to enough to moan about the terrible pain in his hip. There were some x-rays and a number of CT scans.  Then they wheeled him into surgery to sedate him before reducing the hip (shoving the ball back into the socket).

In yesterday’s mail, we received a very nice bill from Colorado Surgical and Critical Care Associates for those services, and, as a bonus, we also received Blue Cross’ Explanation of Benefits (EOB) for those same charges.

I found it very interesting that Blue Cross approved the $132 for “Moderate Sedation >5, ” but denied the $1056 for “treatment of displaced hip,” because the latter was “not deemed medically necessary by the payer.”  So what’s with that?!? It seems like everyone agrees that reducing a hip is an extraordinarily painful procedure, and that the patient must be sedated in order to do it, but evidently actually putting the ball back into the socket is not really essential.

Now tell me, how would one be expected to get around on a dislocated hip? We shall appeal, and I’m sure Blue Cross will see it rationally, but I thought it was funny enough to laugh about.  A merry heart does good like a medicine, right?


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