Insurance denies coverage 6 months post op

MT1

Yesterday we got an update from our insurance company saying we owe $20,000.oo because the plastic surgery to close my bmx is elective. I called prior to having the operation and was told the surgery would be covered. I am floored. I didn't have reconstruction so, I am sure my surgery saves them money. I am in a panic.

Fearless_One

Oh my - I would start by contacting your PS office and asking for the "authorization number" that supposedly was given.   If they can't provide you with that, they never got one and I think you will have to file and appeal with your insurance co.   If they did get one, I would speak to the office manager and have her contact them.   They do this stuff for a living, hopefully they can help you.  

I sure hope all works out for you!  

chrissilini

I believe all surgeries related to mastectomeis are supposed to be covered. There was a law passed in 1998 I think that says surgeries related to breast cancer have to be covered. I know my insurance won't cover fat grafting but so far everything else has been. My ps office did have to contact my insurance company twice to get authorization. First time they needed more info. What more info did they need? I had breast cancer! Don't let them get away with it. It's supposed to be covered. Good luck.

Del11

There's a difference between "elective" and "cosmetic". I'm guessing it was denied because they consider it "cosmetic".  (if you think about it, all breast reconstruction is "elective" yet insurance companies, under most circumstances after mx, consider it "medically necessary")  Anyway...

I think having plastic surgery with no recon is an unusual procedure for most PSs, so the dr's office probably just doesn't know how to code it.  I would think it would be some kind of "reconstruction" but I don't know exactly what.  Maybe someone who had a similar procedure will chime in and let you know what procedure code their dr used.  The starting point would be to talk to your doc's office and find out what they submitted... procedure codes and diagnosis codes.

susan_02143

It is helpful to understand the Women's Health Care Act. Here is a link to get you started.

http://www.dol.gov/ebsa/publications/whcra.html 

MT1

I called the plastic surgeons office and was told not to worry about it, to send them a copy of the Explanation of Benefits and that they would fix it. I, of course, did that. Thanks for the link to the WHCA.

Fearless_One

The law is that any policy that covers mastectomies also has to cover recon.   If a policy does not cover a mastectomy, it is not required to cover recon.

With that being said, I think this is most likely a coding issue as Jeskachi suggested.   I hope PS office gets everything straightened out for you!

MT1

Now the Insurance company has changed the refusal from "not medically necassary" to "the doctor is out of network". Whiley.