Teen in Chronic Pain Had Surgery, but Insurer Won’t Cover It

By Lauren Sausser, KFF Health News

When Preston Nafz was 12, he asked his dad for permission to play lacrosse.

“First practice, he came back, he said, ‘Dad, I love it,’” recalled his father, Lothar Nafz, of Hoover, Alabama. “He lives for lacrosse.”

But years of youth sports took a toll on Preston’s body. By the time the teenager limped off the field during a lacrosse tournament last year, the pain in his left hip had become so intense that he had trouble with simple activities, such as getting out of a car or turning over in bed.

Months of physical therapy and anti-inflammatory drugs didn’t help. Not only did he have to give up sports, but “I could barely do anything,” said Preston, now 17.

No Medical Billing Code

A doctor recommended Preston undergo a procedure called a sports hernia repair to mend damaged tissue in his pelvis, believed to be causing his pain.

PRESTON NAFZ

The sports medicine clinic treating Preston told Lothar that the procedure had no medical billing code — an identifier that providers use to charge insurers and other payers. It likely would be a struggle to persuade their insurer to cover it, Lothar was told, which is why he needed to pay upfront.

With his son suffering, Lothar said, the surgery “needed to be done.” He paid more than $7,000 to the clinic and the surgery center with a personal credit card and a medical credit card with a zero-interest rate.

Preston underwent surgery in November, and his father filed a claim with their insurer, hoping for a full reimbursement. It didn’t come.

But the final bill did: $7,105, which broke down to $480 for anesthesia, a $625 facility fee, and $6,000 for the surgery.

‘Trying to Wiggle Out’

Before the surgery, Lothar said, he called Blue Cross and Blue Shield of Alabama and was encouraged to learn that his policy typically covers most medical, non-cosmetic procedures.

But during follow-up phone calls, he said, insurance representatives were “deflecting, trying to wiggle out.” He said he called several times, getting a denial just before the surgery.

Lothar said he trusted his son’s doctor, who showed him research indicating the surgery works. The clinic, Andrews Sports Medicine and Orthopaedic Center, has a good reputation in Alabama, he said.

Other medical providers not involved in the case called the surgery a legitimate treatment.

A sports hernia — also known as an “athletic pubalgia” — is a catchall phrase to describe pain that athletes may experience in the lower groin or upper thigh area, said David Geier, an orthopedic surgeon and sports medicine specialist in Mount Pleasant, South Carolina.

“There’s a number of underlying things that can cause it,” Geier said. Because of that, there isn’t “one accepted surgery for that problem. That’s why I suspect there’s not a uniform CPT.”

CPT stands for “Current Procedural Terminology” and refers to the numerical or alphanumeric codes for procedures and services performed in a clinical or outpatient setting. There’s a CPT code for a rapid strep test, for example, and different codes for various X-rays.

The lack of a CPT code can cause reimbursement headaches, since insurers determine how much to pay based on the CPT codes providers use on claims forms.

More than 10,000 CPT codes exist. Several hundred are added each year by a special committee of the American Medical Association, explained Leonta Williams, director of education at AAPC, previously known as the American Academy of Professional Coders.

Codes are more likely to be proposed if the procedure in question is highly utilized, she said.

Not many orthopedic surgeons in the U.S. perform sports hernia repairs, Geier said. He said some insurers consider the surgery experimental.

Preston said his pain improved since his surgery, though recovery was much longer and more painful than he expected.

By the end of April, Lothar said, he’d finished paying off the surgery.

Partial Payment

A billing statement from the surgery center shows that the CPT code assigned to Preston’s sports hernia repair was “27299,” which stands for “a pelvis or hip joint procedure that does not have a specific code.”

After submitting more documentation to appeal the insurance denial, Lothar received a check from the insurer for $620.26. Blue Cross and Blue Shield didn’t say how it came up with that number or which costs it was reimbursing.

Lothar said he has continued to receive confusing messages from the insurer about his claim.

Both the insurer and the sports medicine clinic declined to comment.

The Takeaway

Before you undergo a medical procedure, try to check whether your insurer will cover the cost and confirm it has a billing code.

Williams of the AAPC suggests asking your insurer: “Do you reimburse this code? What types of services fall under this code? What is the likelihood of this being reimbursed?”

Persuading an insurer to pay for care that doesn’t have its own billing code is difficult but not impossible, Williams said. Your doctor can bill insurance using an “unlisted code” along with documentation explaining what procedure was performed.

“Anytime you’re dealing with an unlisted code, there’s additional work needed to explain what service was rendered and why it was needed,” she said.

Some patients undergoing procedures without CPT codes may be asked to pay upfront. You can also offer a partial upfront payment, which may motivate your provider to team up to get insurance to pay.

KFF Health News is a national newsroom that produces in-depth journalism about health issues. 

My Story: Kratom Helps Treat Fibromyalgia

By Jim Hunter

The following narrative is not meant as medical advice. I am not a medical professional. I am simply relating my own experience.

Most of my adult life I have suffered from a variety of symptoms that were never diagnosed by any of the doctors I saw. Eventually, I became aware that these symptoms seemed to be consistent with the list of symptoms that appear under the heading of fibromyalgia. The most conspicuous symptom was painful muscles all over my body. The one symptom often associated with fibromyalgia that I did not have was insomnia.

Do I actually have fibromyalgia? I don’t know. What I have is an assortment of symptoms that, when compared to a checklist for fibromyalgia, make it look pretty close to that mysterious affliction.  Since there seemed to be no reliable objective signs of fibromyalgia, and I seemed to have almost all the subjective ones, it seemed reasonable to diagnose myself as having it.

I treated it for a long time (years) by taking more ibuprofen than is recommended for pain relief. The ibuprofen did help some, so I took more than I should have. I am not recommending anyone else do this, but I didn’t see an alternative at the time.

Then I discovered kratom. I don’t recall how I happened to run into it. But I discovered that when I took small doses of kratom regularly throughout the day, the fibromyalgia symptoms simply went away. Above all else, I didn’t hurt anymore.

Kratom even cleared up the stomach and intestinal problems. That was a surprise. I figured that anything that tasted as harsh as kratom wouldn’t help my stomach, but it did.

As long as I didn’t take too much kratom, I didn’t have any loopy feelings. I didn’t mind the slightly euphoric sensations it sometimes generated, but I learned to fine tune it so I didn’t experience that. It simply took away all the muscle aches and pains, fatigue and stomach problems. I felt normal again and was productive.

A Complication

That happy state facilitated by kratom lasted for years. But then I ran into a glitch. I got an inguinal hernia that strangulated. The surgeon was able to push it back in, but that was clearly just a temporary solution. Clearly, I needed surgery. One can die a nasty death from a strangulated hernia.

There was a complication about whether the local hospital could do the operation or whether my condition would require a bigger hospital with an intensive care unit. They eventually agreed on the local hospital (which is what I wanted), but the only glitch was that I had barely mentioned my use of kratom and sort of played it down. I was pretty sure most of the professionals in the medical field would be suspicious of it. Kratom is, after all, reported to have a mild opioid-like effect.

I’m 83 years old. I was perfectly willing to take any reasonable risk in surgery. I am not going to live forever, and I suspect that the end will not be decades off.

But I did feel obligated to the hospital that agreed to do the operation. I had to either level with them about the kratom I was taking or get off it. I knew that if I explained everything in detail, it would raise questions again about who should do the operation and when. I imagined there might be an issue with a possible interaction of kratom with anesthesia.

I decided to get off the kratom, at least long enough for the operation. There might be some withdrawal symptoms, but they were described in the literature as mild to moderate and short lived.

So, I began phasing out my kratom, for which I calculated I needed about two weeks. Two weeks stretched into three and then four. I was feeling horrible – considerably worse than what was described as kratom withdrawal. This was neither short, nor mild or moderate.

Then my wife put her finger on the problem. The symptoms for withdrawal and fibromyalgia, though similar, were not exactly the same. I was experiencing less nausea, but more pain. The fibromyalgia was back in full force. At that point, as I saw it, I had no choice. I took a little bit of kratom once again and felt fine, except for the hernia.

It was while on the minimal dose of kratom needed for the fibromyalgia that I went in for surgery. After the operation, the anesthesiologist reported that her part of the operation went well. I was relieved. However, another problem emerged. An expected two or three-hour operation with laparoscopic surgery turned into a seven-hour ordeal.

I still cannot visualize the exact nature of the unexpected problem the surgeon encountered. Apparently, my bladder was drawn into and tangled up with the hernia. The surgeon, who had done this operation thousands of times, had never seen it before and nobody else had heard of it.

The surgeon was able to unravel the problem and repair the hernia. This led to yet another problem. I had expected to be in the hospital most of one day, but they kept me in the hospital overnight and, as far as I knew, might keep me hospitalized even longer.

By three in the morning, I was beginning to experience moderate to severe pain. The medication given to me by the night nurse didn’t touch the pain. I realized I had no choice. I had to confess my sin -- the incomplete and unsatisfactory way I told them about the kratom -- and plead for mercy.

I called in the night nurse and explained the whole thing. She was very nice about it, let the head nurse know right away, and notified the surgeon as soon as he arrived in the morning.

To make a long story short, arrangements were made for me to be released from the hospital so I could resume my regime of small doses of kratom.

I had lots of minor aches and pains from being worked on so hard and so long during the operation, while in an awkward position. They had raised my legs a considerable angle to the ground, expanded the inner cavities of my body with CO2, and done God knows what to separate my scrotum, testicles and whatever else from the hernia. But with some Aleve, these were now manageable pains. 

Do I have any advice? Not really. The nearest thing I can offer is to say that, should the situation rise again, I would simply tell the medical people about my dependence on kratom. And if they insisted that I get off it before they would do the surgery, I would not have the surgery done.

Jim Hunter lives in Maine. He is a retired social worker.

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Send your stories to editor@painnewsnetwork.org.