My HMO won't authorize medical clearance for out of plan TT. What can I do?

Question

I'm having a TT w/ Lipo on 6/2/17, in Miami, FL. My doctor at Kaiser ordered the pre OP labs requested by my PS, but won't give me a medical clearance. I would prefer to take care of this before I go to Miami. My PS obviously can't clear me. What can I do? Has anyone had this problem? I'm in Vacaville, CA

Kenneth Hughes, MD · Answer

The lab results are normally faxed to the PS, so the PS's office will determine if the the results of the lab tests fall withing the ranges to clear you for the TT.  Postpone your surgery in Miami until you are certain your PS has cleared you.  Otherwise, you could be paying for travel and a procedure that will may not be reimbursed based upon the PS's policy.Kenneth Hughes, MD, Board Certified Plastic SurgeonLos Angeles, CA

Miguel Delgado, MD · Answer

It is important to know why you are not getting medical clearance and address the issue. Evidently your doctor has determined that it is not safe for you to have surgery. If you believe that it is only because you are having surgery outside of your insurance plan and nothing to do with your health, talk to your surgeon about seeing someone else about your pre-operative tests, you will probably have to pay out of pocket. Good luck.

Curtis Wong, MD · Answer

It means your doctor has some concerns about your health and your ability to go through the procedure.  More concerning to me is why are you traveling to FL when you could easily have the procedure done in Vacaville or a surrounding community.  Insurance doesn't cover tummy tucks and if you're paying out of pocket as I assume, you should be able to go anywhere you like and it's ALWAYS better to stay closer to home as problems do arise that will require frequent follow-ups.  And good surgeons will do thorough exams and review of your history to determine if a medical clearance is needed at all so is your surgeon pushing this responsibility off to someone else or was there a medical problem that you are being managed by another doctor that your surgeon wants the clearance from?  If you go to FL without your clearance, its not likely that you will be having your surgery.

Steven Turkeltaub, MD · Answer

Have the lab tests sent to your plastic surgeon for review. Also, discuss with him/his office the problem that you are having getting medical clearance, why that is the case and what you should do at this point in time.What exactly is the reason that your Kaiser MD won't give you medical clearance? Is it because of a medical reason or some other non-medical reason? If it is due to a medical one and you do have significant medical issues, that is important - as opposed to just a bureaucratic or other one which should be less likely to lead to the need to cancel your surgery. Steven Turkeltaub, MD

Don Fontana, MD · Answer

In 99.9 % of the patients requesting a TT, insurance does not pay. Almost no matter what the circumstances, insurance companies (especially HMOs) will not pay for this operation. Unfortunately, you are stuck !More importantly is your medical clearance. If your physician  can not clear you for medical reasons, do not have the  surgery, especially if you are out of town.

Richard P. Rand, MD, FACS (retired) · Answer

These are 2 very different things. If you are struggling to get medical clearance there may be significant reasons the doctors feel it isn't safe. Don't do it if it isn't safe! If you are looking for insurance to cover a TT, this will likely not happen because this isn't considered medically necessary in virtually all cases. Also, with so many fine Bay Area plastic surgeons, why would you go to FL? Who's going to deal with any issues when you get back home??

My HMO won't authorize medical clearance for out of plan TT. What can I do?

Answers (6)

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