Insurance Hell!!

Blue Cross Blue Shield of New Jersey approved me for removal of excess skin (codes:  15830 & 15847) 3 weeks before my surgery.  I had my surgery on 8/24/09 with great results.  Friday I received a  notice from my insurance company stating they did not pay the doctor because my policy does  not cover this surgery!  You can imagine how upset I am right now. I written a letter if appeal to the insurance company, but now I am afraid my doctor is going to ask me for the $5,500.  I've paid out of pocket almost $14,000 for my tt (muscle tightening, lift with implants and liposuction).

Have anyone experienced anything like this before and if so what happened?

Thanks in advance for your advice.

Sherline

Did you get an approval letter from them for those CPT codes?  If so, then mail it back in with your rebuttal.  If they still don't pay, then write your Department of insurance advising them that you had this procedure done knowing that they would pay for the procedure.  I am guessing that they denied it without reviewing the prior history that they had approved it beforehandl.

 Good luck.

If this is Horizon, which I unfortunately have, they don't cover excess skin removal post bariatric surgery without SEVERE medical necessity.  But if you submitted with evidence of medical necessity, and they approved (I assume you and/or your surgeon have it in writing), then you have to appeal.  Maybe it was a "mistake" that they are hoping you aren't smart enough to challenge.  This is a common insurance company trick.

I received a copy of Horizon's policies on reconstructive surgeries from someone about a year ago, so I don't have a link, but I have a copy of what their policy was then, and I don't think it has changed.  If you want a copy, please send me your email address by PM.

 

Every procedure code and even level of the procedure has it's own specific procedure code... Unless your physician performed and billed for what and only what was authorized that is the only way they will pay. If you upgraded your procedure to a new procedure then he legally can not bill for what he did not do... basically what it comes down to is that if you were auth'd for a panniculectomy which would be 1 procedure code and you had a tummy tuck done.... that would have it's own separate procedure code and that would not be one of the codes that was authorized. I would start at the insurance company to verify what these 2 codes are... and then compare that to what your physician billed them for.

Thank you for responding to my post.  I did submit a letter of appeal and included a copy of the approval letter from the insurance company.  My doctor's office submitted the bill only for the procedure codes which where approved prior to surgery.  I paid out of pocket the balance of my procedures.  Now I just have to wait and see what Blue Cross Blue Shield decide to do.  Thank you to everyone for your advice.

Sherline