Too good to be true-NYS emp benefits

so i contacted UHC with a procedure code of 15847 which is what the plastic surgeon gave me. UHC told me it is a "eligible" code.  I asked several times, "so is this a covered procedure"? she said yes its an eligible coded......so...what do i do..i call again to get someone else and they said the same....could this be true.....????



Betsy

It may be eligible (meaning it's not excluded from your plan completely) but you still probably must prove medical necessity and get prior authorization right?

Hi LL.......i did ask that as well...strangely they said no prior authorization on it and that came from 2 different reps answering the question. 

This cant be!!  Again too good to be true I think..Even the surgeons office (the secretary) said before she gave me the code said,,,"im telling you its not covered" which i was a lil annoyed at, cuz there are different types of policies.  I know my policy def covers panni removal.  The other empire plan (state employees also) does not...so for her to be kinda nasty in answering,,,,wasnt necessary...surgeon will be hearing about that when i go to him again for the 3rd time.....

Call them and ask them what is the criteria to have this procedure covered. Mine was also covered but I had to mee the requirements first.

Hi MZ,,,,,I did ask them that also and again they said as long as doc states its necessary its covered.  I dont get it as I told LL above.....very strange.......im not getting my hopes up.....what requirements did u have if you dont mind my asking.

That is not a back door approval for a tummy tuck. The person you're talking to is likely superficially familiar with the issue you're trying to clarify. I think it's showing up on her screen as a code that doesn't require precertification, which is different then implying that it's a covered benefit. If you asked her about the CPT code represent a facelift, you'd get the same answer I suspect.

CPT15847 is a CPT code created specifically by the feds and the AMA to distinguish a cosmetic abdominoplasty from an abdominal panniculectomy (CPT 15830). It is not a covered benefit by insurers and has zero RVU (relative value units) attached to it. It is designed for tracking purposes only and was only created a few years ago so surgeons had some way to accurately report a cosmetic surgery (there was confusion to that point as the old CPT code didn't distinguish b/w cosmetic and functional procedures)