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HMO Coverage for facial wasting
Aug 31, 2004

I have Blue Shield HMO coverage from the California Public Employees Retirement System. I was denied coverage for reconstructive surgery(malarplasty) for facial wasting and the decision was upheld by an independent medical review done through the Department of Managed Health Care. I have read several of your responses to past questions and you have cited the California Health and Safety Code Section 1367.63 which requires mandatory coverage for reconstructive surgery as defined in the statute. My Blue Shield Evidence of Coverage states that they cover "medically necessary" reconstructive surgery. In their denial the health plan indicated that the requested procedure is cosmetic in nature and therefore, not medically necessary. The physician that conducted the independent medical review concurred with their assessment and upheld their denial. In the physicians analysis he writes: "There is no physiologic or functional benefit to midfacial infra/submalar fat. Furthermore, the indication for restoring a normal appearance depends upon the degree to which the existing state represents a departure from normal. In the case of this patient's midfacial lipoatrophy, the departure from a normal appearance is cosmetic in nature." His statements are directly contradictory to the statements of two Plastic Surgeons and my primary care physician which have all independenly described the facial wasting as "moderately severe". Does the Health Plan Evidence of Coverage supercede the Health and Code Section 1367.63? Would it be worth the money and effort to consult with an attorney? Thank you.

Response from Ms. Franzoi

I don't know from a legal standpoint which controls. In addition, what is meant by a "normal appearance" is left somewhat to interpretation. It might be worthwhile to discuss with an attorney.

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