There are numerous reconstructive procedures that may be covered under your medical insurance program. But plastic surgery is unique amongst medical practitioners in that the insurance companies largely take the position that…anything that involves plastic surgery is unnecessary and cosmetic in nature. While this may not be what their policies say and certainly isn’t their public position, but when you see it from a plastic surgeon’s perspective that statement doesn’t seem too far fetched.
Over the years in my Indianapolis plastic surgery practice, I have faced responses from insurance companies such as…does that child’s cleft lip really need to be repaired ?(medical director of prominent and major health insurance carrier)…there is no need to remove a 30 pound hanging abdominal pannus before knee replacement…burn scar contracture release for better neck motion is a cosmetic procedure. I would like to say that such responses, and hundreds of other seemingly incredulous denials of procedures, is because they did not have sufficient information to make the right judgment. But sadly this is not so. Plastic surgeons are notorious for their photographic documentation and medical detail which is always provided in advance of undergoing any procedure.
Based on our ongoing and continuous unsavory insurance experience, patients need to be aware of several important issues regarding coverage of certain plastic surgery procedures. First and foremost, never call or believe whatever is said to you if you call your health insurance company and ask if a certain procedure is covered. Many patients start off in consultations telling me that their procedures is going to be covered…or I have good insurance and it will cover it. That belief is often dead wrong. At the least, it is ill conceived even if well intentioned. There is a complete disconnect between a customer service agent and the people and process that actually approve a procedure to be covered. This is akin to asking the teller at your local bank if your home loan application would be approved.
Determining whether a plastic surgery procedure is covered under your policy requires what is known as a formal pre-determination. That is a written process and one that takes time, often a minimum of two to three weeks, after a request letter is received. This letter is done by the plastic surgeon’s office and contains the patient’s history, symptoms, medical necessity, diagnosis and procedure codes, and often photographs of the physical problem. This letter is absolutely necessary because it will generate a written response from the insurance carrier stating whether the procedure is covered or denied. Never proceed to an elective plastic surgery (even if it seems there is no way it could not be considered reconstructive), or allow anyone to take you there, unless you have written confirmation of the procedure approval. Surprisingly, written confirmation does not always guarantee that it will eventually be covered and paid. (seems confusing doesn’t it?) But no written confirmation puts you in financial peril should they refuse payment after the fact…and they have every right to do so since most policies make it clear that pre-determination is a requisite for coverage.
There are exceptions to pre-determination but they are of an acute and urgent nature. If you are in an emergency room or an existing patient in a hospital and develop the need for plastic surgery care, a pre-determination is not necessary beforehand and can be approved after the procedure is done. But for an elective procedure, pre-determination is always needed.
Dr. Barry Eppley
Indianapolis, Indiana