I want to report here how my own insurance issues are addressed, in case someone can use it as a template (insurance plans permitting) or other guidance for the strategy to get an abdominoplasty in conjunction with my hernia repair. Keep in mind that your insurance plan may vary in language, and your medical issues almost certainly will as well, but the outlines of my approach may help someone else.
Background: after I lost most of my weight in 2007, my DS surgeon suggested that I could apply to my insurance (at the time, HealthNet, under a fully-funded California insurance plan covered under CA law) to cover reconstructive surgery. They submitted for 4 procedures: (1) circumferential body lift; (2) thigh lift, (3) brachioplasty; and (4) breast lift. I assumed all would be deemed cosmetic. To my surprise, HN approved the breast lift (the one I was LEAST interested in, and still am), but denied the rest for "lack of medical necessity."
I actually didn't want my DS surgeon to do this work, frankly - so I consulted with a couple of board certified reconstructive plastic surgeons. One of them mentioned that there was a law passed in CA in 1999 that required CA insurance companies to cover reconstructive surgeries in some circumstances that did NOT require medical necessity. So I researched it, of course.
The law was written in response to the denial of coverage for a kid who was born without both internal and external ears, who was denied reconstructive surgery to give him external ears - which of course would not help him hear, just make him look more normal. The law as written required coverage by fully-funded insurance plans "delivered in CA" (e.g., the company HQ was in CA, and thus falling under the CA law) for reconstructive surgery to correct "abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease," to improve function or to improve appearance to the extent possible, so long as the improvement in appearance was more than minimal (i.e., not merely cosmetic).
So, I decided to appeal the denials of the other procedures to the CA Department of Managed Health Care, to get them to enforce the law, by getting a plastic surgeon to write a request for precertification tracking that language. And I WON at the DMHC. And then HealthNet refused to cover it anyway.
Thus began a multiyear saga. I prodded and prodded the DMHC to prosecute HN for refusing to follow their decision overturning the denials. But it clearly was going to take YEARS to get any action out of them. So I found a class action attorney to take the case, by convincing him of the correctness of my legal position, and that there were many many patients similarly situated ($$$), insured not just by HN, but also BCBS, Kaiser, etc., who were not following the law. I became the lead plaintiff in the case against HN.
Unfortunately, that concurrent prosecution against HN also took a long time. In 2009, my company got sold and I lost my job - but got a nice "parachute" due to some stock options not being underwater. I decided to go ahead with my surgeries as a self-pay, hoping to eventually be reimbursed, because I was technically still employed (but told to stay home for 3 months), and insured, and had disability insurance. Turned out that was a good thing.
I had my first procedure, which was the brachioplasty, as well as a lower facelift and upper eyelid blepharoplasty (I never expected either of those to be covered - they were the things that bothered me the most though, and I had fat transplanted from my arms to my hollowed-out cheeks). I had the other procedures scheduled over the following 2 months. Unfortunately, I had a horrible experience post-op - I could not believe the amount of pain that was involved, and it was exacerbated by what I believe to be an all-too-common psychiatric reaction to Reglan (metoclopramide), which was prescribed to counteract the motility-slowing effects of the opioid pain medication. I began having extreme anxiety and panic attacks, and suicidal ideation, and I chickened out of the further surgeries. I ended up needing months of antidepressant therapy, and regained 35 lbs. I have never gotten back to my pre-op self - attention and memory issues, and I still have occasional anxiety attacks.
Eventually, the DMHC ordered HN to change their criteria for making determinations of coverage for reconstructive surgeries, and reviewed the policies and procedures for many other CA insurance companies to comply with the law - but by that time, I was no longer covered by HN. In the class action suit, let's just say the case was settled, and the attorney went on to use my case as a template to sue multiple other insurance companies on behalf of people whose post-bariatric reconstructive surgeries were denied. At least one of them, against BC of CA, resulted in a published $3.2M settlement. Kaiser was also sued, and had to change their procedures.
Over the last couple of years, I have lost the regained weight, but our financial situation got much worse, and my new job in 2010, which I still have, is with a law firm in VA, so my insurance is under VA law. I still wasn't in the mood to submit myself to reconstructive surgery anyway, so I just let go of the idea.
Around 2013 or so, I became aware (I think my DS surgeon noted it in a yearly exam) that I had a small incisional hernia just above and to the left of my navel. I had a CT scan in 2014, which noted that it was about 2.5 cm. The surgeon said I didn't need to do anything about it - yet. I have also had a lipoma on my right flank, at my waist, which has been slowly growing over the last 10 years or so - it is about the size of a goose egg. Surgery was recommended, but not urgent.
And now - I have finally started exercising here in Heaven's Waiting Room - I'm taking a pilates class with people mostly older than me in amazingly good shape. And doing abdominal exercise, I realized that the hernia was HURTING. That, combined with some gut issues I've been having (probably related to eating too many carbs, but still ...), let me to get another CT scan and a consult with a local surgeon. In making the appointment, I was expecting to be told that I was fine, and I was mostly trying to get my husband back to see the surgeon for his recurrent inguinal hernia, after he saw the guy shortly after we moved here - the surgeon (hereinafter Dr. G) had told him he could wait, but Charles had been complaining that it was hurting, so I made back-to-back appointments for BOTH of us, so I could force him to see the surgeon and get scheduled for his problem to be fixed.
To my surprise and dismay, Dr. G gave Charles another pass (Charles of course minimized his complaints when we got there), but said I needed to do something about my hernia, which is now about 4 cm - sooner rather than later. So I asked him if he was going to use mesh, and he said yes, together with component separation - and I told him I didn't want mesh, and asked if I got the long-delayed abdominoplasty too, could I avoid mesh? And he said yes, but he didn't do abdominoplasty, but there is a really good local surgeon, Dr. M, who specializes in doing abdominoplasty with ventral hernia repair.
OK, now comes the complications. Dr. M is out-of-network. And I have met my high annual deductible, and more than half of my maximum out-of-pocket expenses (which is $6K, ABOVE the deductible), and our plan-year ends August 31st. What to do?
Well, as you know, the first thing is to look at that old EoC - just like we tell everyone. And to my surprise, my VA plan has language regarding reconstructive surgery that is not terribly far off of the CA language! Moreover, there is fairly generous language regarding getting out-of-network providers treated as in-network - at least in theory. Here are the terms I found:
Regarding what is considered In-Network:
Section 1.1A.3 [In-Network benefit rates apply] if “the Member’s Preferred Provider refers the Member to a provider who is not a Preferred Provider” and/or “a Preferred Provider is not reasonably available.”
So I have begun the process of trying to get preauthorization to see Dr. M from my insurance company, to see Dr. M at in-network rates. This is more than a little tricky, since I have out-of-network benefits - with a HUGE additional deductible and and HUGE additional out-of-pocket maximum. I NEED this to be deemed a benefit not available in-network, and/or treated as in-network because my in-network provider referred me. Also, my plan includes language that leaves me open to the balance billing of the out-of-network provider's charges over what they would pay an in-network provider, even if they treat the OON provider as an in-network benefit. BUT - if it is treated as in-network, my already met deductible applies, as does my out-of-pocket maximum for the year - leaving my exposure at about $2300. I can live with that.
Therefore next issue to address is getting both my PCP and Dr. G to provide referrals to BCBS and to get them to ACT on them in advance. Apparently, there may be a Catch-22 in this - because I have OON benefits (that I don't want to apply), I don't need preauthorization to see Dr. M. But I want to be sure the treatment by Dr. M will be paid at in-network rates - IN ADVANCE. I don't want to go into this with $17K of possible exposure (another $8K OON deductible and another $9K out-of-pocket max). At the very least, if I am facing NEW OON deductibles and OOP expenses, I would wait until Sept. 1st and get them to apply to whatever I do NEXT year.
So, I have written referral letters for both my PCP and Dr. G to sign, which incorporate the specific language of the EoC. This is what I sent to Dr. G's office:
I have a consult scheduled with Dr. M on August 8th. In the meantime, I have to figure out how to get my insurance company to review the referrals from my PCP and Dr. G, and to at least preauthorize the consult. Or whether I'm going to toss the dice and argue that it should be treated as in-network AFTER surgery, and just go ahead and git 'er done now.
Even with all my experience doing insurance appeals, it ain't easy - every plan is different. But maybe this can help someone see how they can approach a similar issue.
More as events unfold.
Background: after I lost most of my weight in 2007, my DS surgeon suggested that I could apply to my insurance (at the time, HealthNet, under a fully-funded California insurance plan covered under CA law) to cover reconstructive surgery. They submitted for 4 procedures: (1) circumferential body lift; (2) thigh lift, (3) brachioplasty; and (4) breast lift. I assumed all would be deemed cosmetic. To my surprise, HN approved the breast lift (the one I was LEAST interested in, and still am), but denied the rest for "lack of medical necessity."
I actually didn't want my DS surgeon to do this work, frankly - so I consulted with a couple of board certified reconstructive plastic surgeons. One of them mentioned that there was a law passed in CA in 1999 that required CA insurance companies to cover reconstructive surgeries in some circumstances that did NOT require medical necessity. So I researched it, of course.
The law was written in response to the denial of coverage for a kid who was born without both internal and external ears, who was denied reconstructive surgery to give him external ears - which of course would not help him hear, just make him look more normal. The law as written required coverage by fully-funded insurance plans "delivered in CA" (e.g., the company HQ was in CA, and thus falling under the CA law) for reconstructive surgery to correct "abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease," to improve function or to improve appearance to the extent possible, so long as the improvement in appearance was more than minimal (i.e., not merely cosmetic).
So, I decided to appeal the denials of the other procedures to the CA Department of Managed Health Care, to get them to enforce the law, by getting a plastic surgeon to write a request for precertification tracking that language. And I WON at the DMHC. And then HealthNet refused to cover it anyway.
Thus began a multiyear saga. I prodded and prodded the DMHC to prosecute HN for refusing to follow their decision overturning the denials. But it clearly was going to take YEARS to get any action out of them. So I found a class action attorney to take the case, by convincing him of the correctness of my legal position, and that there were many many patients similarly situated ($$$), insured not just by HN, but also BCBS, Kaiser, etc., who were not following the law. I became the lead plaintiff in the case against HN.
Unfortunately, that concurrent prosecution against HN also took a long time. In 2009, my company got sold and I lost my job - but got a nice "parachute" due to some stock options not being underwater. I decided to go ahead with my surgeries as a self-pay, hoping to eventually be reimbursed, because I was technically still employed (but told to stay home for 3 months), and insured, and had disability insurance. Turned out that was a good thing.
I had my first procedure, which was the brachioplasty, as well as a lower facelift and upper eyelid blepharoplasty (I never expected either of those to be covered - they were the things that bothered me the most though, and I had fat transplanted from my arms to my hollowed-out cheeks). I had the other procedures scheduled over the following 2 months. Unfortunately, I had a horrible experience post-op - I could not believe the amount of pain that was involved, and it was exacerbated by what I believe to be an all-too-common psychiatric reaction to Reglan (metoclopramide), which was prescribed to counteract the motility-slowing effects of the opioid pain medication. I began having extreme anxiety and panic attacks, and suicidal ideation, and I chickened out of the further surgeries. I ended up needing months of antidepressant therapy, and regained 35 lbs. I have never gotten back to my pre-op self - attention and memory issues, and I still have occasional anxiety attacks.
Eventually, the DMHC ordered HN to change their criteria for making determinations of coverage for reconstructive surgeries, and reviewed the policies and procedures for many other CA insurance companies to comply with the law - but by that time, I was no longer covered by HN. In the class action suit, let's just say the case was settled, and the attorney went on to use my case as a template to sue multiple other insurance companies on behalf of people whose post-bariatric reconstructive surgeries were denied. At least one of them, against BC of CA, resulted in a published $3.2M settlement. Kaiser was also sued, and had to change their procedures.
Over the last couple of years, I have lost the regained weight, but our financial situation got much worse, and my new job in 2010, which I still have, is with a law firm in VA, so my insurance is under VA law. I still wasn't in the mood to submit myself to reconstructive surgery anyway, so I just let go of the idea.
Around 2013 or so, I became aware (I think my DS surgeon noted it in a yearly exam) that I had a small incisional hernia just above and to the left of my navel. I had a CT scan in 2014, which noted that it was about 2.5 cm. The surgeon said I didn't need to do anything about it - yet. I have also had a lipoma on my right flank, at my waist, which has been slowly growing over the last 10 years or so - it is about the size of a goose egg. Surgery was recommended, but not urgent.
And now - I have finally started exercising here in Heaven's Waiting Room - I'm taking a pilates class with people mostly older than me in amazingly good shape. And doing abdominal exercise, I realized that the hernia was HURTING. That, combined with some gut issues I've been having (probably related to eating too many carbs, but still ...), let me to get another CT scan and a consult with a local surgeon. In making the appointment, I was expecting to be told that I was fine, and I was mostly trying to get my husband back to see the surgeon for his recurrent inguinal hernia, after he saw the guy shortly after we moved here - the surgeon (hereinafter Dr. G) had told him he could wait, but Charles had been complaining that it was hurting, so I made back-to-back appointments for BOTH of us, so I could force him to see the surgeon and get scheduled for his problem to be fixed.
To my surprise and dismay, Dr. G gave Charles another pass (Charles of course minimized his complaints when we got there), but said I needed to do something about my hernia, which is now about 4 cm - sooner rather than later. So I asked him if he was going to use mesh, and he said yes, together with component separation - and I told him I didn't want mesh, and asked if I got the long-delayed abdominoplasty too, could I avoid mesh? And he said yes, but he didn't do abdominoplasty, but there is a really good local surgeon, Dr. M, who specializes in doing abdominoplasty with ventral hernia repair.
OK, now comes the complications. Dr. M is out-of-network. And I have met my high annual deductible, and more than half of my maximum out-of-pocket expenses (which is $6K, ABOVE the deductible), and our plan-year ends August 31st. What to do?
Well, as you know, the first thing is to look at that old EoC - just like we tell everyone. And to my surprise, my VA plan has language regarding reconstructive surgery that is not terribly far off of the CA language! Moreover, there is fairly generous language regarding getting out-of-network providers treated as in-network - at least in theory. Here are the terms I found:
2.23 Reconstructive Surgery
Benefits for reconstructive surgery are limited to surgical procedures that are Medically Necessary as determined by CareFirst and operative procedures on structures of the body to improve or restore bodily function or to correct a deformity resulting from disease, trauma, or previous therapeutic interventions. *** .. operative procedures on structures of the body to … correct a deformity resulting from disease … or previous therapeutic interventions.Regarding what is considered In-Network:
Section 1.1A.3 [In-Network benefit rates apply] if “the Member’s Preferred Provider refers the Member to a provider who is not a Preferred Provider” and/or “a Preferred Provider is not reasonably available.”
So I have begun the process of trying to get preauthorization to see Dr. M from my insurance company, to see Dr. M at in-network rates. This is more than a little tricky, since I have out-of-network benefits - with a HUGE additional deductible and and HUGE additional out-of-pocket maximum. I NEED this to be deemed a benefit not available in-network, and/or treated as in-network because my in-network provider referred me. Also, my plan includes language that leaves me open to the balance billing of the out-of-network provider's charges over what they would pay an in-network provider, even if they treat the OON provider as an in-network benefit. BUT - if it is treated as in-network, my already met deductible applies, as does my out-of-pocket maximum for the year - leaving my exposure at about $2300. I can live with that.
Therefore next issue to address is getting both my PCP and Dr. G to provide referrals to BCBS and to get them to ACT on them in advance. Apparently, there may be a Catch-22 in this - because I have OON benefits (that I don't want to apply), I don't need preauthorization to see Dr. M. But I want to be sure the treatment by Dr. M will be paid at in-network rates - IN ADVANCE. I don't want to go into this with $17K of possible exposure (another $8K OON deductible and another $9K out-of-pocket max). At the very least, if I am facing NEW OON deductibles and OOP expenses, I would wait until Sept. 1st and get them to apply to whatever I do NEXT year.
So, I have written referral letters for both my PCP and Dr. G to sign, which incorporate the specific language of the EoC. This is what I sent to Dr. G's office:
I need a formal referral from Dr. G to Dr. M, in writing, with a detailed explanation of why I need to be referred to Mussman, so I can get this out-of-network service paid at in-network rates (including getting the benefit of my already-maxxed out deductible and nearly maxxed out out-of-pocket maximum). Dr. G has already referred me to Dr. M for repair of my incisional ventral hernia, together with an abdominoplasty to be performed at the same time, as well as removal of a large lipoma on my right flank, but I need it in detail and in writing.
According to my Evidence of Coverage (Section 1.1A.3), I am entitled to have this procedure performed at In-Network benefit rates if “the Member’s Preferred Provider refers the Member to a provider who is not a Preferred Provider” and/or “a Preferred Provider is not reasonably available.” I would like to ask Dr. G for a Letter of Medical Necessity which uses this specific contract language, as well as the following EoC language regarding reconstructive surgery:
Therefore, I would like Dr. G to write a referral along the following lines (adding or subtracting whatever he thinks appropriate):
I have conducted a surgical consult with my patient Diana Hamlet-Cox regarding her ventral incisional hernia. I have reviewed a current CT ordered by her primary care provider, as well as a comparison CT provided by the patient from July 2014, and her medical records. The incisional hernia is enlarging (it is now about 4 cm), and is becoming painful, and is interfering with the patient’s ability to exercise, as well as possibly causing bowel issues now and increased likelihood of issues in the future.
The patient is status post-bariatric surgery (duodenal switch) performed in 2003, and her weight is stable. She also has a significant amount of excess abdominal skin from massive weight loss, reporting a total sustained loss of about 120 lbs. She is currently near her lowest post-op weight. She reports that she was approved for medically necessary reconstructive surgery in 2007, but chose to defer surgery for personal reasons. In addition, she has a slowly growing but sizeable lipoma on her right flank, which is causing some discomfort. Now that she needs to undergo an abdominal surgery on the incisional hernia, which I have recommended that she not delay, I recommend that she combine these procedures for several valid and medically justified reasons.
As a stand-alone procedure, the incisional hernia would need to be repaired using component separation with mesh. However, the patient does not want a mesh hernia repair, for medically sound reasons. She has had multiple abdominal surgeries (duodenal switch [laparoscopic with open hand port], including appendectomy, cholecystectomy, hiatal hernia repair and umbilical hernia repair; right salpingo-oophorectomy [open]; C-section [open]; and exploratory laparoscopy with ovarian cyst reduction), and is therefore at enhanced risk of needing a future abdominal surgeries, e.g., for a bowel obstruction, and having a mesh repair could complicate future procedures. She has a history of forming adhesions. She also has a prominent diastasis recti from her years of morbid obesity, as well as the previously repaired umbilical hernia, resulting in a further compromised abdominal wall. A more appropriate and medically necessary repair, under these circumstances, is to perform the incisional hernia repair without mesh, in conjunction with and supported by the previously authorized reconstructive surgical repair of her abdominal wall to correct the deformity caused by the treatment of her disease of morbid obesity and the therapeutic intervention (bariatric surgery) therefor, as well as the lipoma removal, in order to maximize the durability of the hernia repair, to provide correction of her abdominal deformity, as well as to minimize risk, cost and recovery time for the patient to have these procedures done at the same time.
In my opinion, these procedures should be performed by a reconstructive plastic surgeon having expertise not only in abdominal wall repair, but also in concomitant abdominal incisional hernia repair. To my knowledge, there is no preferred provider of this surgical procedure available in the Abrazo network, nor other local BCBS network, with the requisite skills and experience to do this complex repair in one procedure. Dr. M, a colleague in the Phoenix area, has this experience and expertise, and I therefore am referring my patient to him for these procedures.
According to my Evidence of Coverage (Section 1.1A.3), I am entitled to have this procedure performed at In-Network benefit rates if “the Member’s Preferred Provider refers the Member to a provider who is not a Preferred Provider” and/or “a Preferred Provider is not reasonably available.” I would like to ask Dr. G for a Letter of Medical Necessity which uses this specific contract language, as well as the following EoC language regarding reconstructive surgery:
2.23 Reconstructive Surgery
Benefits for reconstructive surgery are limited to surgical procedures that are Medically Necessary as determined by CareFirst and operative procedures on structures of the body to improve or restore bodily function or to correct a deformity resulting from disease, trauma, or previous therapeutic interventions. *** .. operative procedures on structures of the body to … correct a deformity resulting from disease … or previous therapeutic interventions.
Benefits for reconstructive surgery are limited to surgical procedures that are Medically Necessary as determined by CareFirst and operative procedures on structures of the body to improve or restore bodily function or to correct a deformity resulting from disease, trauma, or previous therapeutic interventions. *** .. operative procedures on structures of the body to … correct a deformity resulting from disease … or previous therapeutic interventions.
Therefore, I would like Dr. G to write a referral along the following lines (adding or subtracting whatever he thinks appropriate):
I have conducted a surgical consult with my patient Diana Hamlet-Cox regarding her ventral incisional hernia. I have reviewed a current CT ordered by her primary care provider, as well as a comparison CT provided by the patient from July 2014, and her medical records. The incisional hernia is enlarging (it is now about 4 cm), and is becoming painful, and is interfering with the patient’s ability to exercise, as well as possibly causing bowel issues now and increased likelihood of issues in the future.
The patient is status post-bariatric surgery (duodenal switch) performed in 2003, and her weight is stable. She also has a significant amount of excess abdominal skin from massive weight loss, reporting a total sustained loss of about 120 lbs. She is currently near her lowest post-op weight. She reports that she was approved for medically necessary reconstructive surgery in 2007, but chose to defer surgery for personal reasons. In addition, she has a slowly growing but sizeable lipoma on her right flank, which is causing some discomfort. Now that she needs to undergo an abdominal surgery on the incisional hernia, which I have recommended that she not delay, I recommend that she combine these procedures for several valid and medically justified reasons.
As a stand-alone procedure, the incisional hernia would need to be repaired using component separation with mesh. However, the patient does not want a mesh hernia repair, for medically sound reasons. She has had multiple abdominal surgeries (duodenal switch [laparoscopic with open hand port], including appendectomy, cholecystectomy, hiatal hernia repair and umbilical hernia repair; right salpingo-oophorectomy [open]; C-section [open]; and exploratory laparoscopy with ovarian cyst reduction), and is therefore at enhanced risk of needing a future abdominal surgeries, e.g., for a bowel obstruction, and having a mesh repair could complicate future procedures. She has a history of forming adhesions. She also has a prominent diastasis recti from her years of morbid obesity, as well as the previously repaired umbilical hernia, resulting in a further compromised abdominal wall. A more appropriate and medically necessary repair, under these circumstances, is to perform the incisional hernia repair without mesh, in conjunction with and supported by the previously authorized reconstructive surgical repair of her abdominal wall to correct the deformity caused by the treatment of her disease of morbid obesity and the therapeutic intervention (bariatric surgery) therefor, as well as the lipoma removal, in order to maximize the durability of the hernia repair, to provide correction of her abdominal deformity, as well as to minimize risk, cost and recovery time for the patient to have these procedures done at the same time.
In my opinion, these procedures should be performed by a reconstructive plastic surgeon having expertise not only in abdominal wall repair, but also in concomitant abdominal incisional hernia repair. To my knowledge, there is no preferred provider of this surgical procedure available in the Abrazo network, nor other local BCBS network, with the requisite skills and experience to do this complex repair in one procedure. Dr. M, a colleague in the Phoenix area, has this experience and expertise, and I therefore am referring my patient to him for these procedures.
I have a consult scheduled with Dr. M on August 8th. In the meantime, I have to figure out how to get my insurance company to review the referrals from my PCP and Dr. G, and to at least preauthorize the consult. Or whether I'm going to toss the dice and argue that it should be treated as in-network AFTER surgery, and just go ahead and git 'er done now.
Even with all my experience doing insurance appeals, it ain't easy - every plan is different. But maybe this can help someone see how they can approach a similar issue.
More as events unfold.
