What is Osteoarthritis?
Osteoarthritis occurs when the protective tissues at the end of your bones wear down, worsening over time. Primary osteoarthritis has no known cause, while secondary osteoarthritis can be caused by an injury, infection, another disease, or deformity. The knees and hips are the most common body parts for osteoarthritis, and joint pain is the most common symptom. As the cartilage wears down, the ends of your bones can thicken, forming bony spurs.
According to singlecare.com, more than 32.5 million adults in the United States have osteoarthritis, with about 62 percent of those being women. Osteoarthritis in the knees is very common, with more than 14 million Americans experiencing symptomatic knee osteoarthritis. While treatment can help with osteoarthritis symptoms, the condition cannot be cured. Medications, physical therapy, and surgical procedures can often help reduce pain, allowing the patient to maintain mobility.
What Are the Most Common Treatments for Osteoarthritis?
The first line of treatment for osteoarthritis may be over-the-counter NSAIDs like aspirin, ibuprofen, or naproxen sodium (Aleve). If these drugs fail to relieve the pain of osteoarthritis, you may be prescribed Voltaren, Zipsor, or Arthrotec which are NSAIDs that come in topical and oral forms. Voltaren in topical form is now available over the counter. Other prescription NSAIDs for treating osteoarthritis include Celebrex, Nalfon, Indocin, Ponstel, Mobic, Daypro, and Feldene. Analgesics don’t treat inflammation, but instead, work to block the signals in your body that produce pain.
Tylenol is an over-the-counter analgesic, while Cymbalta is a prescription analgesic. Over-the-counter topical osteoarthritis creams include Icy Hot, Zostrix, Capzasin, Bengay, lidocaine patches, and Voltaren. Corticosteroids are sometimes used for severe OA flare-ups, often injected directly into the affected joint. These drugs include Celestone, Soluspan, Solu-Cortef, Depo-Medrol, Kenalog-40, and Zilretta. Opioid medications change the way you feel pain but do not address inflammation, however, they can be sedating and habit-forming, and can also impair balance. Ultram is sometimes prescribed for knee and hip OA, but other opioids are not typically prescribed, particularly for the elderly who may already have balance issues.
Does Insurance Cover Osteoarthritis Treatments?
The Affordable Care Act enacted provisions to ensure coverage and access to insurance for those living with osteoarthritis. Under the ACA, you cannot be refused insurance coverage or be charged higher premiums as a result of your osteoarthritis. Most osteoarthritis treatments are covered under healthcare insurance, although as with most treatments you may be required to start at the low end (as far as cost) and work your way up in order for your insurance to pay for your treatment. Your doctor may be able to re-submit a claim along with a letter detailing why the treatment is medically necessary in your case. Your insurance company may deny a claim for a newer osteoarthritis drug, claiming it is “experimental,” or “investigational.”
Are Osteoarthritis Treatments Considered Medically Necessary?
Most osteoarthritis treatments are considered medically necessary, and there are not a lot of “new” osteoarthritis drugs that are still considered experimental or investigational. This means that your osteoarthritis treatments will likely be considered medically necessary in most cases. If your doctor believes a surgical procedure is the best course of action for you, you may have to try several other drugs, injections, or topical therapies before your insurer will approve the surgical procedure. Of course, this will depend on the insurance you have, where you live, and other factors as well.
Why Are Osteoarthritis Claims Typically Denied—And What Can You Do About It?
It’s important to read your denial letter carefully. A denial is not the same thing as a rejected claim. You could simply have a problem with your claim such as missing information, a missing code or authorization, or another type of clerical error. You may have failed to get pre-authorization, or inadvertently chosen an out-of-network provider. If your claim really was denied, read the explanation for the denial.
Your insurer may have determined that the treatment is not medically necessary or that the recommended drug or treatment is experimental. Your doctor may be able to re-submit the claim, along with a letter of explanation that details why you need the drug or treatment. If the claim is still denied, you can file an internal appeal according to your plan documentation. If the appeal is not successful, you can file an external appeal where a third party will make the decision, taking it out of the hands of your insurer. It can give you peace of mind to have a legal advocate on your side who will handle your claim denial, allowing you the time and space you need to deal with your osteoarthritis. While any insurer can deny a claim, they might include Anthem Blue Cross, Blue Shield, Health Net, Kaiser, UnitedHealthcare, and Aetna.
How the Law Offices of Scott Glovsky Can Help When Your Insurance Company Won’t Approve Osteoarthritis Treatment
If your insurance company won’t approve osteoarthritis treatment or you’ve received an osteoarthritis insurance denial, the Law Offices of Scott Glovsky can help. It is important to note that “medically beneficial” is not the same thing as “medically necessary.” In other words, just because a procedure might be beneficial to you does not mean the insurance company will consider it medically necessary.
Attorney Scott Glovsky and his legal team will fight hard for you and the treatments you need. Our firm is well-known for our integrity and experience, as well as our passion and commitment. We have a successful track record for our prior clients, and also consistently provide a high level of personal care and support. Contact the Law Offices of Scott Glovsky today for a comprehensive consultation.
