Insurance help

[jener8er]

Hello everyone, I don't post very often but I do check up on you all every day! I have a problem with my insurance co - Health Net of Ca - they are denying revisions to my reconstruction surgery, saying it is cosmetic and not medically necessary. Can anyone here help? I had bilateral (one side delayed, the other prophylactic) DIEP recon in June 06, with revisions in Nov 06. Before it can be finished up with tattoos, I need some more revisions: lift of proph side, nipple revision, scar revisions etc. They first denied the whole thing, now today they said they will cover revisions to my cancer side as it is directly related to my dx, but not my other side as it is cosmetic. Arrrggghhhh! Any lawyers out there? I wouldn't be doing ANY of this if it wasn't for my cancer dx, don't they get that??? Very frustrated here. Thanks in advance for any help.
Jen

[Joanne S]

Jen,I know how frustrating that is, and I can see how it could be construed as cosmetic, but if that's the case. all of the reconstruction is cosmetic.

However, it might be beneficial to have you doctor submit additional requests with supportive documentation for pre-authorization surgical approval to your insurance company. Also if you can see a psychiatrist and have them document the negative emotional repercusions and importance and mental health necessity for the surgery. Until the insurance company approves, I would require again and again in writting to the insurance company, each time up the level in personnel, even to the executive level and CEO---sometimes persistence pays.

Be sure to point out that the Federal Law related to covered health care for breast reconstruction; "...Surgery and reconstruction of the other breast to produce a symmetrical appearance..."

Here's the link:
http://www.plasticsurgery.org/patien...ederal-Law.cfm


Also see:
Before the law was passed only about 50% of all states required insurance companies to pay for breast reconstruction and related procedures, and even then the laws did not apply to all insurance companies. The federal law covers all states, whether or not they have their own laws on the subject.

1. Before the law, breast reconstruction and related procedures were not covered because they were considered “merely cosmetic” and because they did not treat “medically threatening” conditions. With the new law comes acknowledgement of the importance of breast reconstruction for women’s overall health and well being.

Link:
http://www.thebreastcaresite.com/een...b?OpenDocument

Good Luck and let us know how it goes.

[hutchibk]

It is definitely federal law for them to cover whatever is necessary to get it right and the way you want it...