Unraveling The Billing Conundrum: Understanding Insurance Coverage For Revision Surgery

Whether or not revision surgery is billed to insurance depends on the type of surgery, the insurance provider, and the patient's location. In the US, most insurance plans cover a major portion of the costs for procedures deemed medically necessary, such as surgeries to save a life, improve health, or avert possible illness. However, cosmetic surgery is typically not covered by insurance unless it is deemed medically necessary, such as breast reconstruction after breast cancer surgery.

When it comes to revision surgery, the insurance provider's response may vary depending on the reason for the revision. For example, in the case of a failed prior surgery, the insurance company may question whether the surgery actually failed or if the patient was non-compliant with the requirements of the first surgery. It is important for patients to provide documentation and pre-op testing results to support their claims. Additionally, the surgeon should be aware of the exact need for the revision surgery and the patient's compliance with the original procedure.

The cost of revision surgery can vary depending on the extent of the revision and the surgeon's policy. Some surgeons may not charge an additional fee for revisions within a certain timeframe or scope, while others may only cover minor revisions. Patients may also be responsible for anesthesia and operating room costs. It is recommended that patients consult with their insurance provider and surgeon to understand the financial implications of revision surgery.

Insurance companies' decisions vary

The response from insurance providers regarding revision surgery depends on several factors. These factors influence whether the insurance company will cover the costs of the procedure or not.

Firstly, insurance companies will often question whether the initial surgery failed or if the patient was non-compliant with the requirements of the first surgery. For example, in the case of bariatric surgery, the insurance company may question whether the patient was eating past the pouch or band. It is imperative that the patient and their surgeon are on the same page and can provide evidence to support their request for revision surgery. This evidence may include pre-operative testing, such as an MRI, CT scan, or endoscopy, as well as a general description of the patient's compliance with diet and exercise recommendations.

Secondly, insurance companies may be more likely to cover the costs of revision surgery if it is deemed medically necessary. For example, Medicare may cover plastic surgery to reconstruct a breast following a mastectomy for cancer, to improve the function of a malformed body part, or to repair damage after trauma or an accidental injury. Additionally, if the revision surgery is required due to a new type of procedure that did not exist at the time of the original surgery, insurance coverage may be more likely.

Thirdly, the patient's individual insurance plan will determine the extent of coverage for revision surgery. Different insurance plans have different coverage levels for surgical procedures, and it is important for patients to familiarize themselves with the specifics of their plan. Some plans may have higher out-of-pocket costs for revision surgery, while others may have lower caps on out-of-pocket expenses.

Finally, the cost of revision surgery itself can vary depending on the surgeon and the extent of the revision required. Minor revisions performed under local anesthesia in the surgeon's office may be less expensive, while more extensive revisions requiring general anesthesia and an operating room may incur higher costs.

Pre-testing to prove the need for surgery

Pre-testing is a crucial step in determining the need for surgery and ensuring patient safety during the procedure. Here are some important aspects of pre-testing to prove the need for surgery:

Purpose of Pre-Testing

The primary purpose of pre-operative testing is to identify and address any potential issues that could complicate the surgery or impact the patient's health. This includes evaluating the patient's overall health, identifying risk factors, and optimising their condition to reduce the chances of perioperative morbidity and mortality.

Types of Pre-Tests

Common Pre-Surgery Tests

• Blood tests: These are done to assess the patient's general health, check for infections, and evaluate organ function. Common blood tests include complete blood count (CBC), liver function tests, coagulation studies, and blood chemistry panels.
• Imaging scans: These help surgeons determine the nature and extent of the problem. Common imaging scans include X-rays, Magnetic Resonance Imaging (MRI), and Computed Tomography (CT) scans.
• Heart tests: Pre-surgery heart tests are especially important for patients undergoing heart surgery or those with cardiovascular risk factors. These may include an electrocardiogram (ECG or EKG) and pulmonary function tests.
• Urinalysis: This test can diagnose kidney and bladder infections and detect the presence of drugs in the body.
• Other tests: Depending on the patient's health, age, and the type of surgery, other tests may be necessary, such as colonoscopy, upper endoscopy, or heart stress tests.

Factors Considered for Pre-Testing

The need for pre-operative testing is determined by various factors, including:

• Clinical history and examination findings: The patient's medical history, comorbidities, and physical examination results are crucial in deciding which tests are necessary.
• Perioperative risk assessment: The surgical risk is assessed as low, intermediate, or high, depending on the likelihood of a cardiac event during or after the procedure. This risk assessment helps determine the need for certain tests.
• Signs and symptoms: Patients with active cardiovascular disease symptoms or new/unstable cardiopulmonary symptoms often require specific tests like electrocardiography and chest radiography.
• Underlying health conditions: Pre-existing conditions such as diabetes, blood disorders, sleep apnea, or heart problems may require specific tests to ensure the patient can safely undergo surgery.

The Role of Insurance

The cost of pre-surgery tests can be significant, and they may or may not be covered by insurance. It is essential to check with your insurance provider to understand what tests are covered and to what extent. Additionally, discussing the expected costs and insurance coverage with your surgeon or healthcare provider is crucial to avoid unexpected financial burdens.

In conclusion, pre-testing plays a vital role in proving the need for surgery and ensuring patient safety. It involves a range of tests tailored to the patient's health, risk factors, and type of surgery. Understanding what tests are necessary and how they are covered by insurance is an important part of the pre-surgical process.

Comply with the surgeon's pre-operative instructions

Complying with your surgeon's pre-operative instructions is essential to ensure a safe experience and positive outcome from your surgery. Here are some detailed instructions to follow in the weeks and days leading up to your revision surgery:

Three Weeks or More Before Surgery:

• Practice good fitness habits. Upper body stretches and low-weight strength training can improve your posture and strength during recovery.
• Eat a healthy, balanced diet and consider taking supplements like Vitamin C, Vitamin D, and Zinc. Avoid crash dieting, overeating, and excessive alcohol consumption.
• If you smoke, quit at least two weeks before surgery, as smoking impairs healing.
• Maintain good hygiene and address any illnesses promptly. Inform your surgeon of any serious changes in your health.
• Plan for your recovery by scheduling time off work and arranging support for housework, childcare, shopping, and transportation.
• You may need to undergo pre-surgical testing and lab work, so ensure you schedule and complete all necessary tests.
• Do not have any dental work done within six weeks following surgery, as it increases the risk of infection.

Two to Three Weeks Before Surgery:

• Continue your healthy lifestyle habits and fitness routine, but avoid anything too strenuous that could cause injury.
• Preplan your schedule for the days surrounding your surgery and share it with your support system.
• A pre-screening nurse will contact you for a general health history evaluation. Inform them if you have diabetes, high blood pressure, take blood thinners, or have a cardiac condition.
• Continue to avoid second-hand smoke and practice good hygiene and hand-washing to prevent catching a virus or cold.

One Week Before Surgery:

• Fill your prescriptions for pain medication and antibiotics, if applicable.
• Confirm your transportation to and from the surgical centre, ensuring a responsible adult will drive and accompany you.
• Make arrangements for a responsible adult to stay with you for the first 24 hours after surgery.
• Continue to practice healthy habits, nutrition, and light fitness routines. Avoid saunas, hot tubs, and steam baths.
• Do not smoke and limit alcohol consumption.
• Prepare your home for recovery by removing trip hazards, having fluids and ice packs on hand, and organising any necessary mobility aids like crutches or a walker.
• Discontinue the use of aspirin, ibuprofen, fish oil supplements, and green tea, as these can increase the risk of bleeding.

One Day Before Surgery:

• Pack a bag for the day of surgery, including paperwork, medications, glasses or contacts, and a method of payment for prescriptions.
• Shower using anti-bacterial, fragrance-free soap. Do not use scented skin creams, moisturisers, hair spray, perfume, or cosmetics. Remove nail polish but not gel or acrylic nails.
• Avoid alcohol and refrain from smoking.
• Eat a light meal the night before surgery to reduce the risk of post-operative nausea.
• Do not eat or drink anything after midnight, including water, coffee, tea, candy, or gum. Take any morning medications with a small sip of water.
• Confirm your transportation and arrival time for surgery.
• Get plenty of rest and avoid unnecessary stress.
• Wear loose, comfortable clothing and flat shoes without jewelry or body piercings.

Cosmetic surgery is rarely covered

However, there are some situations where cosmetic surgery may be deemed medically necessary, such as in the case of reconstructive surgery after a mastectomy or other disfiguring injury. In these cases, insurance may cover the cost of the procedure. For example, breast reconstruction after a mastectomy is covered and is required by law under the Women's Health and Cancer Rights Act (WHCRA).

Additionally, the surgical correction of any cosmetic defect that significantly impacts the function of the body part in question may also be covered by insurance. For instance, a severely hooded eyelid that partially blocks a patient's vision may be covered by insurance if they decide to undergo blepharoplasty.

Ultimately, the decision of whether or not a cosmetic surgery procedure is covered by insurance depends on the insurance provider and the specifics of the patient's plan. Patients should consult their insurance provider to determine if their procedure may be covered.

Proving medical necessity

To prove medical necessity, you must provide valid medical evidence demonstrating the need for revision surgery. This evidence should align with the accepted standards for medical practice and treatment. For instance, if you are seeking breast revision surgery due to a ruptured implant, MRIs, ultrasounds, or mammograms can serve as proof for the insurance company. In the case of transgender individuals seeking top surgery, providing thorough documentation, including letters from a primary care provider and a mental health professional, can help establish medical necessity.

It is important to note that insurance companies will typically only cover revision surgery if it meets their definition of "medically necessary." This means that the surgery must be necessary to determine a diagnosis or provide proper treatment. For weight-loss revision surgery, insurance providers will often require evidence of complications from the original procedure or unsatisfactory weight loss. They may also request another diet history.

In some cases, insurance companies may deny claims for medically necessary procedures. If your claim is denied, you can contact an insurance claim lawyer for assistance. An appeal process may be available, allowing you to provide additional medical evidence and supporting documentation to demonstrate the medical necessity of the revision surgery.

Frequently asked questions