Advertisement
The Body: The Complete HIV/AIDS Resource
Follow Us Follow Us on Facebook Follow Us on Twitter Download Our App
Professionals >> Visit The Body PROThe Body en Espanol
   
Ask the Experts About

Workplace and Insurance IssuesWorkplace and Insurance Issues
           
Rollover images to visit our other forums!
Recent AnswersAsk a Question
  
  • Email Email
  • Glossary Glossary


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.



Previous
Eligible for Individual Insurance with HIV?
Next
about insurance

  
  • Email Email
  • Glossary Glossary

 Get Email Notifications When This Forum Updates or Subscribe With RSS


 
Advertisement



Q&A TERMS OF USE

This forum is designed for educational purposes only, and experts are not rendering medical, mental health, legal or other professional advice or services. If you have or suspect you may have a medical, mental health, legal or other problem that requires advice, consult your own caregiver, attorney or other qualified professional.

Experts appearing on this page are independent and are solely responsible for editing and fact-checking their material. Neither TheBody.com nor any advertiser is the publisher or speaker of posted visitors' questions or the experts' material.

Review our complete terms of use and copyright notice.

Powered by ExpertViewpoint

Advertisement