What happens if you switch coverage?

Irish Girl · 12-09-2006, 04:22 PM

I had my surgery in April 06. At that time I had United Healthcare for insurance. They covered my procedure. In September, I started a new job and my new insurance is through Regence. The big issue is.......it looks like I will have to have my port put into my abdominal muscle. Where the port is now is risking erosion because there is no fat to cushion between the port and the abdominal wall. I was looking through my benefits book and it states, in the exclusion section "surgery (including reversals), treatment, programs or supplies intended to result in weight reduction, regardless of diagnosis."

What to do? I can't get a straight answer from Regence. And I thought that since my other insurance company did the surgery deed, this wasn't considered a pre-existing condition prior to the new insurance. Regence has covered my office visits for the past two months, so I guess I am really confused. Anyone else have this happen?

I suppose I am just gathering information before I really buckle down and figure out what I am going to do. Any insight would really be appreciated.

beachgirl · 12-09-2006, 05:04 PM

I would fight them tooth and nail if I were you. It's not a reversal so maybe you can find a loophole. From what people on here told me after I was turned down by my insurance and just went to Mexico and paid cash that if I had of fought them you usually win.

12-09-2006, 08:28 PM

Tell them this if they deny coverage:

Technically, your surgery isn't going to be resulting in weightloss. It isn't like you are having the entire band replaced. You are simply having the port moved so that it doesn't wear through the spot it is currently in and cause more problems.

**Alexandra** · 12-10-2006, 08:15 AM

IrishGirl, this isn't a question of a pre-existing condition exclusion, so don't let anyone try to tell you it is.

I think whether they cover this will depend on how your doctor "codes" the procedure. If there's any way they can categorize the surgery without referencing the band they should try to do that. From the language you copied above it's clearly the intent to exclude this procedure based on it being related to your earlier bariatric surgery. Even though you may not be trying to lose weight any longer (congratulations on your success, btw!!), the Lap Band is clearly a bariatric procedure and as such, anything related to it would be excluded.

The other problem is the reason for the port being moved at all. If it's being moved because there is a "risk" of erosion in the future, they won't cover that just based on its not being a treatment of any kind. At this point, this procedure is purely elective, there's no diagnosis at hand.

If, on the other hand, the port has already begun to cause damage to your tissues, the surgeon might be able to code the surgery as a treatment for that. I'm sure there are patients who have subcutaneous ports for other reasons who need this procedure done, so maybe there's a generic code for "subcutaneous portocatheter relocation due to skin damage" or something like that.

Good luck!!

TracyinKS · 12-19-2006, 02:32 PM

I agree with Alexandra! remember Ports are used in other cases... (my grandma had one to distribute pain medication to her back) and I'm sure there are all kinds of other uses in the medical field... CODING IS KEY