*Our Health Care covered SRS at 100%!

[Guest Joyful Mama]

I just had to share this with everyone! Great news! Surprisingly, our BCBS and MVP health care covered our daughter's SRS surgery at 100%! They originally said no!

As we began our plans for surgery I contacted BCBS to ask if they covered it. After being put on hold for 40 minutes, they came back to say no, because there was a 'specific exclusion' attached to our plan by my company (grrr!). They did, however, say they would cover the anesthesia as that is always covered regardless of what type of surgery is taking place. We had decided to pay the $19,000 out of our pocket (huge ouch!).

As the surgery got closer I called BCBS to ask about covering the anesthesia. That is when our luck changed. They very much surprised us by offering to put the proposed bill through a 'courtesy urgent review' to evaluate for possible payment. They requested clinical paperwork from the surgeon, which we had faxed immediately. I also faxed them the AMA document stating health care companies cannot discriminate against coverage for SRS. As they promised, they responded within 48 hours. They called and said the surgery would be covered at 100%. They said if the surgeon declares it is a medical necessity then that overrides the original specific exclusion. We were jumping for joy! This was huge! Just unbelievable and what a relief!

In addition, MVP (CDHP) offered to pay a portion of the surgery also (my husband and I both picked up health care coverage this year in hopes of one of them paying something towards the surgery). The surgery was out of state and although MVP determined it was 'out-of-network, BCBS considered it 'in-network'. Because the surgeon does not subscribe to any health carriers, we had to pay the bill upfront and we were reimbursed within 6 weeks.

I wanted to share this as it may help others in their quest in working with their health carriers to find a way to pay for the surgery. My advice is to not take no for an answer from the health carriers and pursue it further. You can do this by asking for a manager to speak with, request a case manager to be put on it for assistance, or in our case, just luck having the right person answer the phone and willing to fight for you and the cause.

I do believe the proof from the surgeon that it was medically necessary was the key. I do not know if the AMA document I sent made a difference in their decision, but providing whatever you can can't hurt.

We were so, so very thankful this was covered. I will also add that both BCBS and MVP were extremely helpful and respectful throughout the process.

When we told the surgeon that the surgery was being covered she was shocked and stated how rare it has been for health care to cover it. I don't want to get anyone's hopes up unnecessarily, but maybe things are a-changing. Sure is worth the effort to check it out.

[Charlize]

that is great news. I think you are right and one has to stay on top of the insurance companies. we have always had problems with them denying payments for different reasons that were incorrect. My wife is wonderfully efficient at crossing all the t's so eventually they do admit their mistake. one wonders how much money they save by denying what should not be denied.

Hugs,

Charlie

[KathrynJulia]

Thanks Mama for sharing your good fortune:

I'm working on trying to get my insurance coverage changed. But should I be unsucessful, I intend to appeal, appeal, and appeal until I'm sucessful. My employer self insures, but hires a company to manage our coverage.

Maybe someday things will change to cover our needs. Kathryn

[Guest KimberlyF]

The letter of medical necessity is one of the most important tools to turn a no to a yes.

[Guest Muneca59]

thats is awesome, i know that i have been waiting to see when Oxford, will cover this SRS, i have been on hormones since i was 18 and went off them for 4 yrs , then went on again, i worked and had covered health insurance from all the companies i worked for , i had BSBC before but no coverage since they classified it as "COSMETIC " ALTERING the body , i am hoping that this year i can get results , cause i want to laid out my plans for retirement and i want to have the SRS done before i do. If anyone can assist me in obtaining some legal counsel or where i can go get assistance, i would greatly appreciated , I do live in NYC

[Carolyn Marie]

Wonderful news, and excellent advice about your experience, hon. I guess with insurance companies, never taking "no" for an answer is an absolute necessity.

HUGS

Carolyn Marie

[Guest Kylie2112]

I'll have to remember this, since I have BCBS...

[Guest Nikki P]

That is very good to remember, as I have BCBS as well. thanks for sharing!