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-   -   Insurance coverage and surgeries (http://birthmark.org/board/showthread.php?t=5553)

Nasinpgh 11-22-2011 08:47 PM

Insurance coverage and surgeries
 
My daughter just turned three and has a hemangioma on her lower lip. Like many children it was not noticeable at birth, but showed up a couple weeks later. It ulcerated at about 6 weeks and she was treated by pediatric dermatology with a series of steroid injections to heal the ulcer. we were later referred to a pediatric plastic surgery group at Pittsburgh's childrens hospital. They laid out the optionsand we decided to go with the waiting approach for it to involute. The redness is now reduced, the puffiness or volume is somewhat reduced andshe is left with a small scare from the ulcerations. We will be considering surgery in two years before she goes to kindergarten. It will likely be two surgeries, onto reduce the volume and correct the divet in her lower lip and the other to reduce the scar.

My question to those of you who have been through this. Did your insurance cover this? Or are they going to tell me it's not medically needed? Thanks in advance!

missy 11-22-2011 09:33 PM

Hi and welcome!

The answer might depend on your carrier. It also might depend on the doctor. Sometimes insurance will cover, sometimes not. Does your policy say one way or another?

Missy

Nasinpgh 11-23-2011 02:05 AM

I haven't looked into it yet since we are still two years away form it and will probably change carriers before then. Thanks for your answer!

missy 11-23-2011 12:22 PM

When you have to make the decision to change carriers, then keep this in mind. At http://birthmark.org/experts.php you can ask Basia, our insurance expert. She will be happy to help you decide between carriers when the time comes.

Missy

smurph 11-23-2011 09:16 PM

My daughter had surgery on her lip hemangioma last year...very similar circumstances to what you were talking about, ulceration as a baby, surgery at age 5....everything was covered with no problems. Her doctor, at Childrens in Boston, had someone in the office whose job was to specifically deal with insurance companies. She told me that there was a process that they went through and if they ran into trouble they would let me know in terms of appeals, etc. It all went through fine. I'm sure they must submit it to the insurance in a certain way so I got the feeling it was better to let them handle it instead of inquiring/asking questions to the insurance company myself. Maybe that would raise more red flags?

I'm sure it must depend on the insurance company to an extent, so I think it is good advice to talk to Basia and see what she says. I just wanted to let you know that it went very smoothly for us (at the time we had Blue Cross Blue Shield but we have also had Medicaid and Harvard Pilgrim for part of her treatment and laser procedures)...we never had trouble with any of these. I'm wondering maybe because it was on her lip?

Good luck! It's hard to imagine what's going to happen down the road. I did the same thing. And it all worked out! Hang in there!
Shannon

nickbar 12-01-2011 12:19 AM

These surgeries have been approved. It takes some work and dedication to get approval, but I do have some tips. It is important to have a surgeon that is willing to go that extra step to fight the insurance if needed. So, if denied as not medically necessary, you should receive a letter from the insurance co. with a peer to peer review phone number. Provide this number and a copy of the denial to the doctor asap. You doctor can talk directly to the medical director that denied the approval. Often this is enough for a doctor to explain why it is best to have the procedure now vs. later and why it is medically necessary. We really need to take the approach that this is not a cosmetic issue... it is a abnormall occuarance that appeared at birth or shortly after and you are seeking a return to normal or as close to as possible. Please feel free to email me if you need more details and Basia is a great resource if you ever need to appeal.


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