Are there Midwest Surgeons?

[Rocket Ray]

I am trying to get my Gracilis muscle transfer pre- certified with my insurer-United HealthCare.
On my consultation at Mayo they have agreed to pay Dr. Bishops' charges for he is on their list as a provider. Dr. Spinners' cost is not covered because he is not a provider and would be "out of network".
I'm hoping if I explain the procedures and give them a list of the operating codes they will review it and realize that there are no doctors capable in my area, (Chicago suburbs), and then grant me the cost out of network as if in network. Are there any surgeons in the Chicago area capable of muscle transfers? I know about the Mayo BPI teams 3 doctor approach and will try to make them realize that this needs to be done there, with different doctors working together. It just seems so hard to cut thru the insurers red tape. Any response on this subject would be appreciated.

[EllenB]

When John & I were up at Mayo in January, we learned that only three U.S. doctors perform the free functioning muscle transfer (i.e. totally removing the muscle/tendon from one part of the body to another.) Aren't you the guy who's going for the long distance record - i.e. really long time between the injury & this surgery? If so, then the free functioning muscle transfer would be your only option.

The other two doctors are Belzburg at Johns Hopkins & Julia Terzis in Va. You are SO much closer to Mayo than the other locations! Is Alex Shin on the insurance list? Also, when John had his surgery 2 years ago, Mayo was able to run the costs first thru Blue Cross/Blue Shield Minnesota -> BCBS Georgia, which enabled the costs to be treated as in-network. I'm not sure how it works or if non-BCBS carriers might also do this.

I also expect Mayo can write a letter on your behalf to the United Healthcare, explaining the complexity of the procedure. Did your local doctor provide a referral to Mayo? We had to do that.

Don't give up!!!

Ellen

[cbe411]

Ellen just one correction, there are more than 3 doctoros in the US that do this procedure. I personally know of two others so that alone makes 5. I would say that the three that you have mentioned are the most known for the procedure. Dr. Garhboui (sp) in Houston with Dr. Nath and Dr. Chung in Michigan. Dr. Chung has done just one but he can do them.... Todd was his first!

I juat wanted to clarify this, not trying to start a war!

[EllenB]

Hey Court -

I was trying to figure that out, too - and I looked on Nath's website & only saw muscle transfers where the muscle was already in the arm & was just reassigned to a different function. Let me know if he (or the other doctor?) actually do the free muscle transfer from another part of the body.

I agree, it's important to be accurate with all this "stuff".

Thanks!!

Ellen

[EllenB]

Well...just reread your post - sounds like if Todd was the first, he'd certianly know where that transferred muscle came from! How long ago was that surgery?

Thanks again,

Ellen

[admin]

Our insurance (United Healthcare in NC) worked with United Healthcare in Texas and the surgery was almost completely covered. But, the Dr. in Texas accepted our insurance to begin with. It is alot of red tape getting referrals and all but it worked. If your Dr. at Mayo dont accept your insurance, then I rreally dont know what to do in a case like that. I hope it all works out for you!!

[cbe411]

Yes Eleen Todd was the first for a free gracilis muscle transfer in Michigan with Dr. Chung in AnnArbor. Dr. Nath does assist with the free gracilis muscle transfers but Dr.Garhboui (sp) is the main doctor. He is in Houston also. I know this because these are the guys that i Have seen and talked about this procedure with. There might even be another doctor that Nath does this procedure with or someonet hat he used to..... I know things have been constintly changing with him moving around and all.

Todd is about 9 months post op I believe from the free gracilis transfer for biceps (his first op 2 years after crash) and already can keep the arm bent at 90% and in the pool is using a 5lb weight for resistance! thats AMAZING to me!!!!! Dr. Chung who did his, this was a first for him, bet he is excited too!

Hope this helps a bit Ellen!!! Thanks for understanding that I am not trying to start a war here!

COurt xx

[admin]

Thanks for the great response. Yes, Ellen, I am the one who's had a bp injury since my car accident January '87. I probably would've just gone thru life like this if it weren't for my girlfriend,(soon to be wife), Linda who found this website and you good people. We will try to get the operating doctors codes, (even tho Mayo says they can't until it's scheduled)-and I don't want to schedule until I know it's being paid for. (very frustrating) Another option is after getting married to claim it on Linda's carrier-Blue Cross. But I would like to have a functioning arm at the wedding. Even tho Linda or my friends don't care about my arm. I wonder how long I would be out of commission or need therapy? I forgot to ask Dr. Bishop about that. At least if I got married first, there would be someone home here to take care of me post-op.

[Rocket Ray]

Thanks for the great response. Yes, Ellen, I am the one who's had a bp injury since my car accident January '87. I probably would've just gone thru life like this if it weren't for my girlfriend,(soon to be wife), Linda who found this website and you good people.) We will try to get the operating doctors codes, (even tho Mayo says they can't until it's scheduled)-and I don't want to schedule until I know it's being paid for. (very frustrating) Another option is after getting married to claim it on Linda's carrier-Blue Cross. But I want a functioning arm at the wedding. Even tho Linda or my friends don't care about my arm. I wonder how long I would be out of commission or need therapy? I forgot to ask Dr. Bishop about that. At least if I got married first, there would be someone here to take care of me post-op.

[EllenB]

Hi Ray,

When we went thru mediation to settle with the driver who hit John, we needed Mayo to estimate the cost of a future surgery. There was a process they went through to get that, which surely included the likely codes that would be assigned to the procedure. This surgery hadn't been scheduled. I might still have the name of the person who helped facilitate it - if I do, it's at work & I'll send it to you offline Monday.

Would Linda's insurance cover pre-existing conditions? They can get pretty squirrelly about that kind of thing, but I imagine you've checked it out.

Or - another idea - go ahead & schedule the surgery, get the codes, see about coverage - and if it's not covered by your current policy, cancel the surgery until it can be worked out.

But...I think you guys should go ahead & get married! Heavens, why wait?????

Ellen