Knee issue has restricted my mobility and cut down on my shop time

RIGHT KNEE HAS BEEN PROBLEMATIC

My right knee has been quite troublesome for the last year and a half but reached a crisis point at the beginning of this week. Emergency room visit, XRAY and MRI, now meeting Orthopedic Surgeon on Monday to get the final diagnosis and surgery plan. 

Back in 1998 I slipped during a heavy rainstorm while getting out of a car, with my body falling but my right leg pinned by the car door. It ripped all the quadriceps tendons off my knee. They were surgically reattached and my mobility was completely restored however the knee has always been swollen compared to the other one. No problems however.

Eighteen months ago I was grabbing an IBM Z9 computer that was at risk of being scrapped, holding it until it could be picked up by a museum. This machine is about 1500 pounds and very tall, like a monolith. It has four casters for moving it around. 

I was pushing it out of the storage unit where it resided and through the halls of the facility to get it where the moving crew I hired could put it on a trailer. Sounds easy to move, but the mass brings quite a bit of inertia, so it takes quite a shove to get it to start rolling and then quite a bit of counter force to bring it to a stop at the desired place. 

I guess I planted my feet back to get as much push from my legs as possible, but the stance put some torque on my knee and the heel of the other foot as well. The knee began to really hurt and swell up, as did the achilles tendon of the left foot. 

Within a day I was in great pain and couldn't put weight on the right foot. I went to an Urgent Care clinic where the physician took X-Rays and prescribed an MRI to check for soft tissue damage. Here is where things went wrong. At the time, I chose a Medicare Advantage plan (Cigna) for my healthcare partly because of the extremely low monthly fee and tons of free added services it offered. 

For example, I could buy over the counter medications and other medically related objects such as bandages and vaporizers using their card, whose value equaled all the payments I made for the health service. Since these were items I would be purchasing anyway, the health plan was essentially free as a result. 

My international readers (and those who are not already senior citizens) may not be familiar with the Medicare system, so a quick aside is warranted. When someone in the US becomes 65, they are eligible for the Medicare system. Medicare comes in parts A, B, C and D which define the particular types of services offered. 

Part A is for any cost in a hospital setting. Part B is for any costs outside of the hospital such as doctor's visits, lab tests and so forth. Part D is for costs of medications. Part C is the Medicare Advantage alternative to parts A and B. Every medical provider that accepts Medicare agrees to their reimbursement rates and will not charge extra to the patient. 

Having 'original Medicare' is coverage under parts A and B. Part A has a deductible of $1.632 per year and covers all costs for the first 60 days of hospital stay, then has a copay of $408 per day after that. Part B has a deductible of $240 per year and a copay typically 20% of the cost of each item it covers. The premiums are relatively low but bump up based on income, with part A having zero cost and part B running from roughly $175 per month up to $515 per month for incomes of $500,000 a year a more. 

Presciption drugs are not covered by Original Medicare, thus to get Part D one has to purchase a part D plan from some health insurance company. Although not provided by the Medicare system, there is still a charge based on income from Medicare, up to about $80 per month for those with incomes of $500,000 per year or more. The fee for Part D is paid to the insurance company in addition to the income adjustment of $0 to $80. 

Now for Medicare Advantage, the Part C. This is an alternative to Original Medicare, where you sign up with an insurance company to provide all the coverage, thus are quitting Part A and Part B. The government pays a lump sum to the insurance company who is then responsible for paying the medical costs, rather than the government. 

Medicare Advantage plans offer much lower monthly costs to patients and include part D for medications and typically many added services such as eyeglasses, health club memberships and over the counter buying cards. One might ask why the insurance company can add these extra cost services and still offer substantially lower premiums. I didn't really ask that when I first signed up for Medicare, where I chose an Advantage plan from Cigna, one of the big US health insurance companies.

The secret to this is that the insurance company can now decide what treatment you receive and when. With Original Medicare, if a service is covered then there is no prior authorization required. You can visit any doctor or facility that accepts Medicare. All you have to deal with is the deductible for the year and the copayment amount. If a doctor prescribes an MRI, you go to get an MRI. If you need to see an Orthopedic Surgeon, you go directly to one. 

With Medicare Advantage plans, you may have a list of doctors that you must use. The primary care doctor you use must see you and authorize seeing a specialist. Treatments can require prior authorization from the insurance company. Not every treatment that is allowed with Original Medicare is permitted by the insurer. 

There is one other kind of insurance available, called Medicare Supplements. These are plans offered by insurers which charge a monthly premium but cover some or all of the Original Medicare deductible and copayments. A supplement plan insurer has no say over which doctor you can see or what treatment is allowed. If Original Medicare covers it, then the supplement automatically and with not right of interference will pay the copays and deductibles. 

Huge marketing budgets fuel advertising for Medicare Advantage programs. This is because they spend less on a patient than Original Medicare through their right to choose what treatment is received and delays in authorization. 

Back to my visit to the Urgent Care when I couldn't walk on a very painful knee. The doctor there prescribed an MRI and I waited for the imaging center to call with my appointment. No call, so I contacted them. Cigna, my Medicare Advantage program provider, is notoriously slow in doing prior authorizations and often requires multiple requests and denials before approval is granted. The medical office staff told us they call them Cig-NO because of their tendency to initially deny everything.

After more than a month the final answer was in. They would not authorize an MRI. I first had to have Physical Therapy treatments and only after some number of months would they consider an MRI. Two to three times a week for months I went to a facility where they performed exercises and taught me home exercises to gradually straighten the knee and walk with less pain. 

After a week or two from the original incident I was able to walk painfully without crutches. With the exercises and physical therapy my knee (and the achilles tendon injury on the other heel) slowly improved but even after nine months I was limping painfully. 

My wife convinced me to see a medical massage therapist, whose work did pay off in noticeable improvements every week. By April of this year, all the tendon pain was completely gone. As of the beginning of July I had very little knee pain, and by mid July I was pain free walking. 

Not long after the first incident, having learned my lesson about Medicare Advantage, I had switched back to Original Medicare and bought a Medicare Supplement to cover all the deductible and copayments. My wife and I were able to see anyone we wanted and never had to wait for a pre-authorization or deal with repeated denials for any health care after that point. My wife has had back surgery, cataracts removed and other procedures, with zero costs to us and no insurance company interactions. 

At the beginning of this week, I was rising from a chair when I felt a very sharp pain in my knee when it reached about 80% of becoming straight. I fell back in the chair. No pain at all when the leg was bent, I could press on it with no pain and could even put weight on it when bent with no pain. 

However, if I tried to straighten it fully, by about 80% it became very painful and not possible to continue. I can't walk on it because I can't get it straight enough, although when the leg is bent back I can use my toes to hold weight and even hop a bit. 

The emergency room visit took at X-Ray but did not have an MRI machine available that night, so they send me home but recommended a followup with an Orthopedic Surgeon. They gave me a name of one affiliated with the hospital and whose office should therefore prioritize my visit scheduling. 

The next morning, I called the doctor and was in for an assessment within an hour. They prescribed an MRI but the symptoms show a mechanical blockage stopping the full extension and a strong suspicion that this was a torn Meniscus that had moved to a point where it blocked straightening the knee. 

I had an appointment for the MRI within two days, finished the imaging and am waiting for the followup visit with the surgeon on Monday to get the diagnosis and treatment plan. Generally they can fix these torn meniscii or ligaments with arthroscopic surgery with minimum recovery time. That will take place with no prior authorization nor other delays from insurance companies. 

I am now moving around with walkers and an electric scooter. I can't drive because I can't move my leg quick enough to safely operate the vehicle. Neighbors are walking my dog for us in the interim. This has blocked my time in the shop. I have been able to write all the demo programs while I sit in my home, so the time is not totally wasted.