Cali PS patients! The DMHC is about to rule in my favor!

I just received a heads up from the DMHC that they are about to settle a THREE YEAR LONG investigation into Health Net's reconstructive surgery policy, and that it is being settled in my favor.  I also understand that the same analysis is going to be applied to ALL insurance policies regulated by the DMHC. 

If you have insurance with a plan that is regulated by the CA Dept. of Managed Health Care, or the CA Dept. of Insurance, and you want to have reconstructive surgery covered by insurance, you should use the following template letter (or some version of it) to submit for preauthorization to your insurance company BEFORE you have surgery.  Even if they deny you, you can then appeal and when you get before the DMHC, you may find some of your surgery covered.

THIS APPLIES ONLY TO PATIENTS WHOSE PLANS ARE REGULATED BY THE CA DMHC, UNFORTUNATELY.

I am posting this NOW because I also have a law suit pending against Health Net, and I presume the offer to reimburse me for the surgery I already had, and arrange for coverage of the surgeries I have not yet had, will include not only settling the DMHC action against me, but also the law suit.  I presume that they will try to require that settlement of the law suit will require that I keep my mouth shut afterwards.  Therefore, I'm putting this out as a post so that people can have it now, and share it after I am (possibly) silenced.

Sorry about the formatting - OH sucks at maintaining formatting in these posts.  You should put this into a Word document and fix it before giving it to your reconstructive surgeon to fill out and submit on your behalf.

NOTE:  Your PS is probably going to NOT want to do this for you, especially if your PS is in-network for covered surgeries (e.g., breast reconstruction).  S/he knows they can get full price from you, but if they participate with an insurance plan, they will HAVE to accept the plan's reimbursement rate and your copay will be limited.  DON'T LET THEM TELL YOU IT IS A WASTE OF TIME!  If necessary, you may want to change surgeons if they won't cooperate on this!

Here is the letter - again, the formatting is probably going to suck, but it's better than nothing:
~~~~~~~~~

Name of Insurance Company

Precertification

 

 

 

Re:       [Patient’s Name] (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,

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]

Honored to be the first to reply here with a HUGE congrats ! 

I have followed your battle, and its an unusual victory based on principle, and you forced them to adhere to their own plan language !

Hope it had repurcussions all the way to the East coast.

Thanks!

I'm taking bets about whether the insurance companies get together and try to get the law changed: 2:1.5 odds by Jan. 1, 2012, even odds by July 1, 2012.

It is unusual because of the language of the CA statute, which was written in response to a case where a young child who was born with no external OR internal ears, was denied FFcoverage for reconstructive surgery, because there was no medical necessity for him to have an external ear when he couldn't hear anyway.  So, like breast reconstruction post-mastectomy, the law was written to cover reconstructive surgery when there is an abnormal structure of the body, caused by a disease, for which reconstructive surgery can improve appearance to the extent possible, and that improvement is more than minimal. 

During the legislative history, the insurance companies (I presume) tried to get medical necessity put back into the bill - in a clear case of legislative intent, it was deleted.  I can only guess how the insurance companies are going to try to tweak the law, if not revoke it outright.  There is a similar bill that has been pending forever at the Federal level, pushed by the craniofacial surgeons and patient advocate groups.  They can't seem to get it passed - probably because the insurance companies worry that former fatties might benefit in numbers they do not wish to contemplate.