My SO (33, F, AZ) has an HDHP plan through UMR insurance. She’s had back issues for years due to her large breasts, and she’s been seeing chiropractors and doctors for the past year+ regarding getting breast reduction surgery. With the family history of breast cancer, and the paper trail of chiropractic visits and doctors visits we figured she’d be an easy candidate to have the insurance cover the reduction. We found a great surgeon who is willing to do the operation and they submitted the paperwork to the insurance company who came back and basically said that it ‘might’ be covered and that they couldn’t make a determination until the surgery is done and the paperwork submitted?
Essentially what I gathered is that they would submit the surgery under a specific ICD-10 code related to family breast cancer, and that this code IS typically covered by the insurance company. But because its a pre-determination and not a prior authorization, and because the hospital contracts the anesthesiologist, doctors, etc separately then she would have to sign a waiver that basically says the surgery may or may not be covered by the insurance and that we’d sort of have to roll the dice and go through with it and just cross our fingers that the insurance company covers it when they submit the paperwork afterwards.
I’ve never heard of anything like this dealing with insurance companies in the past, and IMHO insurance companies are pretty scummy to put it lightly. So if we don’t get that guarantee of coverage beforehand, I feel like they 100% will not cover because why would they if they don’t have to right? and if it’s a code that they cover, then why can’t they just come out right and say ‘yes this will be covered’ rather than all this roundabout. We’d essentially be gambling with paying at least 10-15k out of pocket if they don’t cover it, so I’m just hoping someone might have some insight.
Has anyone run into a similar situation? How likely is it to be covered? Is there any type of guarantee we can pursue from the insurance company? Any suggestions on this? This surgery would be absolutely life-changing for her/us but not having that guarantee of coverage sets my teeth on edge.
Thanks in advance!
submitted by /u/Orpheus321
[link] [comments]My SO (33, F, AZ) has an HDHP plan through UMR insurance. She’s had back issues for years due to her large breasts, and she’s been seeing chiropractors and doctors for the past year+ regarding getting breast reduction surgery. With the family history of breast cancer, and the paper trail of chiropractic visits and doctors visits we figured she’d be an easy candidate to have the insurance cover the reduction. We found a great surgeon who is willing to do the operation and they submitted the paperwork to the insurance company who came back and basically said that it ‘might’ be covered and that they couldn’t make a determination until the surgery is done and the paperwork submitted? Essentially what I gathered is that they would submit the surgery under a specific ICD-10 code related to family breast cancer, and that this code IS typically covered by the insurance company. But because its a pre-determination and not a prior authorization, and because the hospital contracts the anesthesiologist, doctors, etc separately then she would have to sign a waiver that basically says the surgery may or may not be covered by the insurance and that we’d sort of have to roll the dice and go through with it and just cross our fingers that the insurance company covers it when they submit the paperwork afterwards. I’ve never heard of anything like this dealing with insurance companies in the past, and IMHO insurance companies are pretty scummy to put it lightly. So if we don’t get that guarantee of coverage beforehand, I feel like they 100% will not cover because why would they if they don’t have to right? and if it’s a code that they cover, then why can’t they just come out right and say ‘yes this will be covered’ rather than all this roundabout. We’d essentially be gambling with paying at least 10-15k out of pocket if they don’t cover it, so I’m just hoping someone might have some insight. Has anyone run into a similar situation? How likely is it to be covered? Is there any type of guarantee we can pursue from the insurance company? Any suggestions on this? This surgery would be absolutely life-changing for her/us but not having that guarantee of coverage sets my teeth on edge. Thanks in advance! submitted by /u/Orpheus321 [link] [comments]Read Morer/HealthInsurance