Insurance denial-not medically necessary

File an appeal ASAP with the insurance carrier and ask for a physician review. Is this a group insurance through and employer? If so, ask the employer to contact the insurance carrier and escalate.

I've been reading your thread with interest. I guess you could interpret “not medically necessary “ as meaning that it's not necessary to go out of network if in network plastic surgeons are available. So yes, you are correct. They don’t want to pay the higher cost when they view the in network surgeons as perfectly capable. This is the way many traditional medical insurance plans work . I would certainly appeal the insurance company's decision but remember that they are going to push for the choice that costs them the least. What compelling, and medically relevant, arguments can you make for using the out of network surgeon? Is there something the ps can do for you that the in network surgeons cannot?

I wish you the best in dealing with this and that you balance your fight with the insurance company with having your surgery in a timely fashion. Unfortunately, insurance companies do have the right to deny out of network benefits if they believe that in network surgeons are just as capable. All the best with your appeal

PS: I had to wait 2 1/2 months from dx until my bmx. No insurance issues,just had to coordinate ps and breast surgeons schedules.

I waited a year before starting reconstruction because I wasn’t left flat. Too much skin left and looked crazy. If the delay ends up happening just wanted you to know mine worked out ok

OON doctors will cost you a small fortune. Not only that you have to make sure the facility and stage attending physicians and the lab are all in network. Almost impossible rap when you need to have a procedure ASAP.

My DH and I did appeal a $5k charge OON because that facility was the only one did the procedure my DH had to have. It wasn’t like it was cosmetic. We appealed to our insurance company which is BC/BS and we won the appeal. There were also several mistakes by his doctor beforehand that didn’t help. A doctor can contact BC/BS prior to a procedure OON and get an e caption granted. His DR fumbled the ball and didn’t do that.

Be persistent. We were and it paid off.

Diane

Since your plan is to start immediate reconstruction at the time of your surgery, your OON plastic surgeon obviously works with your breast surgeon.

Do the 2 plastic surgeons who are in network also have experience doing joint surgeries with your BS?

As far as getting a cost breakdown from the OON surgeon, it can get confusing because they have pre-negotiated fees with different insurance plans and carriers, totally different than patient charges, and his fees might also vary depending on which hospital is used.