Californians needing Reconstructive Surgery
Best of luck to you & I hope you get what you want!
Lidia
Check out my Blog! http://momlidsmusings.blogspot.com/
I cannot discuss my particular case.
However, I can direct you to review the following documents, which are the first of many health plan surveys requiring corrective action with respect to reconstructive surgery coverage, and you come to your own conclusion about whether and how to use the template above.
http://dmhc.ca.gov/library/reports/med_survey/surveys/300ful l031411.pdf (see especially pages 8/44 and 24-26/44 (page # of the .pdf))
http://dmhc.ca.gov/library/reports/med_survey/surveys/126fol lowup070511.pdf (see especially pages 11-15/26)
To see if your plan has been reviewed, look for it on the dropdown list here: http://dmhc.ca.gov/library/reports/med_survey/med_default.as px Even if it hasn't been, you can argue that the standards applied in the HN and UHC surveys should be and will be applied to your insurer too. If they don't, you can file an IMR and report the failure to apply the statute to the DMHC.
The trick is to get your reconstructive surgeon to write the letter properly, specifically describing and providing supportive documentation that your skin is an abnormal structure of the body, and that reconstructive surgery can provide you with improved function OR appearance, and that the improved appearance will be more than a minimal improvement (and thus not merely cosmetic). NO MEDICAL NECESSITY IS REQUIRED (though if you have medical necessity, put that in too).
The other part of the trick, however, is to get the surgeon to submit properly - because it is against HIS interest to do so. If you don't get insurance coverage, he gets his full fee - and he knows you'll pay, even if you have to mortgage your house or raid your kids' college fund. If you DO get insurance coverage, and he is an in-network provider, he has to settle for whatever measly amount the insurer decides to pay, plus your copay if any. He did NOT build his business plan on this model - he built it on expecting to do an insurance-covered cleft palate here, a post-mastectomy breast reconstruction there, maybe a hernia repair COUPLED with a bunch of non-covered plastics paid at his full fee - and he is NOT going to be happy to have to devote a larger percentage of his time to insurance-reimbursement-rate discount work. So don't expect him to be gung-ho on writing you a good letter - you will likely have to write it yourself and twist his arm to get him to sign it.
IOW, at what point is it considered reconstructive vs. cosmetic?
HW - 225 SW - 191 GW - 132 CW - 122
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HW - 225 SW - 191 GW - 132 CW - 122
Visit my blog at Fatty Fights Back Become a Fan on Facebook!
Starting BMI 40-ish or less? Join the LightWeights
Name of Insurance Company
Precertification
Re: [Patient’s Name] (Subscriber/Member)
(Subscriber/Member)Subscriber #
To whom it may concern:
I am a board certified plastic surgeon, specializing in reconstructive surgery.
My patient, [name], has asked me to verify that her need for reconstructive surgery meets the terms of the California Health and Safety Code 1367.63, which mandates that [Insurance co.] (as a provider of a health care service plan contract issued or delivered in California on or after July 1, 1999) cover reconstructive surgery that is necessary to achieve the purposes specified in paragraphs (1) or (2) (note: in the alternative, not conjunctive) of subdivision (c) of that section:
1367.63. (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on or after July 1,
Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on or after July 1,1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined in subdivision (d).
(b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for
treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed
individual, competent to evaluate the specific clinical issues involved in the care requested.
(c) "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
(1) To improve function.
(2) To create a normal appearance, to the extent possible.
(d) "Cosmetic surgery" means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.
(e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following:
(1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee.
(2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only a minimal improvement in the appearance of the enrollee.
(3) Denial of payment for procedures performed without prior authorization.
(4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only a minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Services.
Accordingly, I hereby verify that, in my professional opinion and in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, which opinion is clearly supported by [photographs taken by my assistant in my office] and which were submitted/are submitted herewith, [name] has met the terms of this statute insofar as she has:
abnormal structures of the body (see below);
caused by … disease (specifically, morbid obesity, ICD-9 Code 278.01, for which she was successfully treated by bariatric surgery in [date], by [bariatric surgeon’s name or name of practice], which procedure itself was medically necessary and covered by her insurance company [that ins. co.] [substantiated in [reference relevant medical records, e.g., your PCP’s records] records]);
for which condition the reconstructive surgical procedures which I request for pre-certification will create a normal appearance, to the extent possible; and
the procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery such as myself, offer substantially more than a minimal improvement in her appearance.
The abnormal structures of her body caused by morbid obesity include, but are not limited to:
[obviously, put in YOUR conditions, but here are mine as a guide]
a. A significant panniculus that hangs down to her mons pubis, as well as diastasis recti, and a large lipoma on the right lateral waist
b. Significant amounts of loose flesh hanging from her buttocks and hips after massive weight loss
c. Significant amounts of loose flesh hanging from her thighs, in particular her inner thighs but also the back, front and outer thighs, after massive weight loss
d. Significant amounts of loose flesh hanging from her upper arms, armpits and lateral chest wall after massive weight loss
e. Ptotic and pendulous breasts
These are clearly abnormal structures of her body, caused by the disease of morbid obesity and remaining after the successful treatment of that disease by bariatric surgery.
The reconstructive procedures submitted for pre-certification include:
a. Abdominoplasty (15831-22 – excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) – modified 22 is for unusual procedural services; 15847 – Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial placation
b. Bilateral Brachioplasty (15836-50 – Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm)
c. Bilateral Thighplasty (15832-50 – Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh)
d. Lower Body Lift (15835 – Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock)
e. Bilateral Mastopexy or Reduction Mammoplasty
These are clearly appropriate reconstructive surgeries for treatment of abnormal body structures, are not merely cosmetic procedures for reshaping normal structures of the body in order to improve appearance, and these procedures offer substantially more than a minimal improvement in her appearance.
It is my understanding that pre-certification for the above procedures is often denied for lack of medical necessity. However, it is my understanding that if the patient’s condition meets the requirements of the California statute mentioned above, imposing an additional medical necessity requirement is improper.
It is my professional opinion and in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery that [patient’s name] has met the terms of the CA statute mandating coverage of reconstructive surgery for treatment as indicated above.
Pre-certification of the above-mentioned reconstructive procedures is therefore respectfully requested.
Sincerely,
[Reconstructive Surgeon’s name]
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