I am very, very confused and I hope someone can help. I have a high deductible HSA plan from HighMark BCBS. That part doesn’t bother me. About 15 months ago a cyst started growing under my jaw line area. It was clearly infected… It drains a bit, would shrink and grow, and so on. Eventually I got so pissed that I stuck a needle through it and drained it even more. It took a few weeks but it started to feel better and went down a bit. I nick it frequently when shaving and it bleeds a bit, and sometimes get infected.
I scheduled a doctor appointment to get it looked at. He looked at it and could not tell me if it was medical necessary to remove. He said the procedure doesn’t does require prior insurance authorization and said not to worry about it not being covered.
Well, I did worry about it and because I couldn’t get a straight answer, I just decided to not do anything about it. It acted up again a month or two later and I scheduled another appointment, this time with a dermatologist. They were much more helpful and said that he has never heard of these not being covered by insurance…. He provided me with the CPT codes and some variations of what the would do.
When I look this up on HIGHMARK BCBS website, it says this:
“Lesions that cause irritation, pain or bleeding may require removal to alleviate symptoms. Surgical removal is also recommended for any lesion that shows possible signs of malignancy.
Policy Position Coverage is subject to the specific terms of the member’s benefit plan. Removal of a benign skin lesion (e.g., nevus [mole], sebaceous cyst, wart, seborrheic keratosis, or pigmented lesion) may be considered medically necessary when ANY of the following criteria are met:
There is drainage, bleeding, burning, intense itching, or pain associated with the lesion; or Inflammation, as evidenced by purulence, oozing, edema, erythema, etc.; or The lesion obstructs a body orifice, or restricts vision; or There is clinical suspicion of malignancy (e.g., a change in the ABCDEs of skin cancer [asymmetry, border irregularity, color, diameter, evolving or changing in size, shape or color]); or Due to its anatomical location, the lesion is prone to being recurrently traumatized; or A prior biopsy suggests or is indicative of lesion malignancy.”
Some of those conditions are met. But what if the are contested? I am sort of a worry wart and I always assume insurance is going to screw me over and foot me with a huge bill.
It also states this, and I don’t quite understand what this means, assuming insurance did not cover it and I went through with the excision.
Denial Statements Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider can bill the member for the non-covered service.
A network provider can bill the member for the cosmetic service.
Thanks to anyone who can help guide me, or help me ask the right questions of my insurer.
FWIW – This has me worried, because the first doctor I visited through Allina-United gave me ridiculous pricing to remove this pea sized cyst. I swear, I would cut it out myself if I had another pair of hands. Those quoted mediant outpatient pricing at $40,000, then added a bunch of other crap. This is why I stopped dead in the water for my first visit with that provider.
When it came back, I decided to try a dermatologist. They were much better to deal with, more helpful, but ultimately said they can’t answer questions like these, just that normally these are covered… Researched around cysts are normally $600 – $3,000), but was surprised when the estimates from Allina-United network could only give me median and averages prices that were ridiculously sky high.
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I am very, very confused and I hope someone can help. I have a high deductible HSA plan from HighMark BCBS. That part doesn’t bother me. About 15 months ago a cyst started growing under my jaw line area. It was clearly infected… It drains a bit, would shrink and grow, and so on. Eventually I got so pissed that I stuck a needle through it and drained it even more. It took a few weeks but it started to feel better and went down a bit. I nick it frequently when shaving and it bleeds a bit, and sometimes get infected. I scheduled a doctor appointment to get it looked at. He looked at it and could not tell me if it was medical necessary to remove. He said the procedure doesn’t does require prior insurance authorization and said not to worry about it not being covered. Well, I did worry about it and because I couldn’t get a straight answer, I just decided to not do anything about it. It acted up again a month or two later and I scheduled another appointment, this time with a dermatologist. They were much more helpful and said that he has never heard of these not being covered by insurance…. He provided me with the CPT codes and some variations of what the would do. When I look this up on HIGHMARK BCBS website, it says this: “Lesions that cause irritation, pain or bleeding may require removal to alleviate symptoms. Surgical removal is also recommended for any lesion that shows possible signs of malignancy. Policy Position Coverage is subject to the specific terms of the member’s benefit plan. Removal of a benign skin lesion (e.g., nevus [mole], sebaceous cyst, wart, seborrheic keratosis, or pigmented lesion) may be considered medically necessary when ANY of the following criteria are met: There is drainage, bleeding, burning, intense itching, or pain associated with the lesion; or Inflammation, as evidenced by purulence, oozing, edema, erythema, etc.; or The lesion obstructs a body orifice, or restricts vision; or There is clinical suspicion of malignancy (e.g., a change in the ABCDEs of skin cancer [asymmetry, border irregularity, color, diameter, evolving or changing in size, shape or color]); or Due to its anatomical location, the lesion is prone to being recurrently traumatized; or A prior biopsy suggests or is indicative of lesion malignancy.” Some of those conditions are met. But what if the are contested? I am sort of a worry wart and I always assume insurance is going to screw me over and foot me with a huge bill. It also states this, and I don’t quite understand what this means, assuming insurance did not cover it and I went through with the excision. Denial Statements Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records. A network provider can bill the member for the non-covered service. A network provider can bill the member for the cosmetic service. Thanks to anyone who can help guide me, or help me ask the right questions of my insurer. FWIW – This has me worried, because the first doctor I visited through Allina-United gave me ridiculous pricing to remove this pea sized cyst. I swear, I would cut it out myself if I had another pair of hands. Those quoted mediant outpatient pricing at $40,000, then added a bunch of other crap. This is why I stopped dead in the water for my first visit with that provider. When it came back, I decided to try a dermatologist. They were much better to deal with, more helpful, but ultimately said they can’t answer questions like these, just that normally these are covered… Researched around cysts are normally $600 – $3,000), but was surprised when the estimates from Allina-United network could only give me median and averages prices that were ridiculously sky high.
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