As of December 31, 1998, 2,946 surgeons had been trained in the procedure and a total of 2,117 patients had been treated since Genzyme Tissue Repair began marketing the product in 1995. The number of people covered by insurance plans that pay for Carticel as a matter of policy in the United States is 136 million. The procedure cost ranges from $17,000 to $38,000, with an average cost of approximately $26,000 per procedure. Genzyme Tissue Repair charges $10,360 per procedure for the cells.

More severe and chronic forms of knee cartilage damage can lead to greater deterioration of the joint cartilage and may eventually lead to some of the many total knee joint replacements performed each year. Approximately 200,000 total knee replacement operations are performed annually at a cost of about $25,000 each. The artificial joint generally lasts only 10 to 15 years and is considered a poor option for people under the age of 50.

With the information above, and my surgeon's projection that I would require an artificial knee within five years or so, the ACI seems cost-effective. If I were to have a total knee replacement at 40 (I'm now 34) I would in all likelihood require at least one more after that. Given that the cost of ACI and total knee replacement are roughly the same, cost-efficiency becomes a matter of how many of these procedures would be required. ACI holds the promise that a replacement need not be performed. On the other hand, knee replacements have a well-established life expectancy.

I'll admit to being a little reckless in how I handled this. When I found out in September that I might need the surgery, I thought about it for roughly a month and it became apparent that if I waited too long, I'd be missing another summer and the ability to do anything outdoors. Perhaps this is a bit short-sighted but having had three major knee surgeries, I've grown a bit impatient. So, I decided in October that it was time to proceed. Unfortunately, my surgeon's office told me that it would be roughly three months before I'd get the formal approval from the insurance company. The problem here is that there is no established procedure code for ACI within the insurance industry. This then requires that each ACI be handled and reviewed on an individual basis, requiring much closer scrutiny than procedures for which there is a procedure code. On the other hand, my case appeared fairly clear from the surgeon's office point-of-view and they didn't anticipate any problem getting approval, it would just be a matter of time. The surgeon's office told me that they could proceed without complete approval from the insurance company but that I would have to put down $6,000 to cover the surgeon's fee. Apparently my insurance company has been very good about paying for the Genzyme lab fees. They said that I should then expect to receive reimbursement of about $2,000 of this amount, based on previous cases. I decided to do this (I've been involved with this surgeon for roughly eight years now and trust the office) even though it potentially may have costed me $6,000 (worst case in which the insurance company reimbursed for none of the surgeon's charges). In late October, I wrote the check for $6,000 and scheduled the tissue biopsy for early November.

The tissue biopsy was performed on 9 November 1999. By the end of November, all but the anesthesiologist bill had been covered by the insurance company. The remaining bill was cleared by mid-December. The implantation procedure however, would be the more involved both medically and from the insurance perspective. I knew there would be a review involved so I decide to wait for some time before checking on the status of any claims related to this surgery.

Insurance Claim Status Reports

Before initiating any checks on my insurance claims, I recieve a statement from the insurance company indicating that a $28,396.00 claim filed by the outpatient surgical center has been processed and that I owe nothing - nice. Although this claim was filed by the surgical center, the figure suggests that it must contain the Genzyme lab fees.

It's been six weeks since the surgery so I decide to begin following the progress of the remaining insurance claims. At this point, my carrier doesn't have any additional bills, aside from that mentioned above, in process. I call my surgeon's office and they've indeed submitted a claim. As a matter of policy, they will resubmit one at the end of the sixth week if they've not received a reply.

The claims are now "in-the-system" at my insurance carrier and are under review. There have been four claims filed this point.

The fourth claim must include the Genzyme lab fees as well as the surgical center costs. The cost is quite high and I assume this is in part attributable to the fact that I needed twice the number of cells than on average.

I receive a notice from the insurance company regarding the first claim listed above. The insurance company has agreed to pay $468.00 of the $750.00 which was filed by the organization that supplied the CPM machine I used for one month following the surgery. I speak with the rehabilitation equipment supplier and inform them that the insurance company has agreed to pay $468.00 of the $750.00. The supplier indicates that will be acceptable and that I'll not be responsible for the balance.

The unresolved claims are still "in-the-system" at my insurance carrier and are under review.

The unresolved claims are still "in the system" at my insurance carrier and are under review.

The unresolved claims are still "in the system" at my insurance carrier and are under review.

The unresolved claims are still "in the system" at my insurance carrier and are under review.

The insurance company has processed the remaining claims with the following results: (1) the $1,200.00 claim has been denied and (2) $2,057.00 has been sent to the provider on the $5,800.00 claim and my responsibility is $514.00. I have no idea how all of this is going to shake out given that I've already paid $6,000.00 to my surgeon's office.

During a follow-up visit, my surgeon's office tells me that I have a $6000.00 credit in my account. However, their billing person is gone for the day so they're not quite sure what that means. Combined with the information received from the insurance company I still have no idea how much I'm going to owe on this. I'll have to wait until things have been settled at the surgeon's office.

Several unclear and/or miscommunicated bits of information have been resolved over the past few weeks. In short, the way things stand is that I'm responsible for the $514.00 charge associated with the 28 December claim listed in the table above. In addition, I'm also responsible for the $1,200.00 claim denied by my insurance company. There is nothing that I can do about the $514.00 amount. The $514.00 figure represents 20% of the total cost allowed by my insurance company and that's exactly how my policy dictates out-of-network services are to be handled. On the other hand, the $1,200.00 cost, for an assistant surgeon, is certainly something I plan on appealing if I'm able. There is still some uncertainty over the issue of who would perform the appeal, me or my surgeon's office. Regardless, there is no way an ACI procedure could be performed without the aid of an additional surgeon.

The insurance issue has grown increasingly complicated and after all has been straightened out, I find that I'm responsible for roughly $3000 of the surgeon costs. This is about half of the "security deposit" I paid in October so I don't feel terrible about things although it certainly could've turned out better.