Problems with BCBS TX. What are my chances of getting covered?

Question

I met with my PS five weeks ago and he said I'll very likely be covered (24 years old, 32H, years of neck pain, shoulder grooves, not overweight, migraines, and 2 years of chiropractic care). The PS office was told the deadline for a decision is 5/16. BCBS sent a letter on 5/9 requesting ICD-10 and HCPC/CPT codes. The letter also says that if I've been sent this request, it "may serve as a notice of an adverse determination." I haven't heard otherwise, so is this a denial of coverage?

Urmen Desai, MD, MPH, FACS · Answer

I would call the office of your plastic surgeon and speak with the biller in the office.   I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS), a member of the American Society of Plastic Surgery (ASPS) and the American Society of Aesthetic Plastic Surgery (ASAPS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach Trained, Double-Board Certified Plastic Surgeon

Farbod Esmailian, MD · Answer

I am not sure if it is.  In general all that information is submitted by the office with photos and at times the insurance company may ask for more information.  Codes are generally all listed at the time of submission.  Therefore, I am not certain what is exactly going on here.I would recommend calling your PS office and discussing what exactly is going on.  Usually, the letter that is sent is pretty straight forward on whether the procedure was approved or denied.Hope that helps.

Kenneth Hughes, MD · Answer

This is an insurance billing question for your PS's office.  I assume you requested that your PS's office send the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnostic code, and Healthcare Common Procedure Coding System (HCPSC)/Current Procedural Terminology (CPR) codes prior to May 16, 2017 to BCBS of Texas. The HCPSS codes represent medical procedures to Medicare, Medicaid, and several other third-party payers. The  includes services such as ambulance, durable medical equipment, prosthetics, orthotics and supplies when used outside a physician's office. The CPT is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.Kenneth Hughes, MD, Board Certified Plastic SurgeonLos Angeles, CA

Steven Turkeltaub, MD · Answer

From what you described, there is a very high probability that you will be covered by insurance though this also depends on what your particular plan requires. You need to contact your plastic surgeon's office and see where things are at this point in time. Often, the process for certification for coverage is very time consuming and difficult.Steven Turkeltaub, MD

Theodore Nyame, MD · Answer

Your plastic surgery office should be able to tell you if you have been denied.

Arian Mowlavi, MD, FACS (license on probation) · Answer

We have had no problems with getting patients approved for breast reduction universally; you have to be willing to have breast weight remove to meet the minimum breast weight removal that is based on your height, weight, and a scale called the Schnur scale.

Frederic H. Corbin, MD (license restricted) · Answer

Contact your PS and see what their office is doing.  With your description it should be covered.Dr Corbin

James McDonough, MD (retired) · Answer

Insurance coverage should be straightforward, but it isn't. No matter what is sent by the physicians office a series of lost correspondence and prolonged phone delays for the insurance clerk can be expected.  Call your physican's insurance clerk and be pleasant.  Let her know that her sometimes thankless job is appreciated and cheerfully let her know you will be calling back to see what progress has been made.  If you get a denial, and you meet the published criterion of BCBS TX there may be an appeal, lots of phone calls, correspondence, and perhaps a phone conference for your physician and his office.  Be the person that everyone is happy to help.

Ronald V. DeMars, MD (Retired) · Answer

You will have to ask your question to the insurance company or your surgeon to see if a final determination has been made. In general, the insurance companies do not like paying for breast reduction and set their policies to avoid paying as much as possible. At least 75% of the reductions I do are not covered by their insurance these days and pay cash like a cosmetic surgery patient.

Jon Ver Halen, MD, FACS (license suspended) · Answer

Hello and thank you for your excellent question. Unfortunately, dealing with insurance companies is often a challenging task. Your best option to see if your procedure is covered, is to contact your insurer to get details about coverage and requirements before approval for surgery (as you are doing). Given the difficulties of dealing with insurance, you can consider paying out of pocket for the surgery. For our patients, the out-of-pocket expenses for an insurance plan often approximate (or even exceed) the cost for the procedure. You can then obtain documentation from your surgeon to attempt to get reimbursement from your insurer. Any treatment plan should be based on a detailed discussion with equal input from both you and your surgeon.   Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.   Preoperative visualization and surgical simulation with the Crisalix system may help with your decision. The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation in person with a qualified board-certified plastic surgeon.  Good luck! 
  
Best,
  
Jon Ver Halen, MD FACS 
  
Harvard educated plastic surgeon

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