Question
Health insurance question. My insurance will not cover my sons circumcision after initial discharge but....?
When my son was born he had a problem with the skin on his penis being to tight (phimosis) and our pediatrician told us that he could not perform the circumcision for that reason and that we would need to wait 6 to 9 months for medical reasons. Here we are 8 months later and our insurance company will not cover it because they say they will not cover the cost of a circumcision after his initial discharge. They would have covered it if we would have had it done right away but not now. They even initially said they would if it were medically necessary to wait but now have recanted and said that they will not cover it and that preapprovals are never guarantees (thanks for that). I am very disgruntled about this because it was no fault of anyone that it could not take place immediately and it is medically necessary that it is done now - this is not a cosmetic choice since the phimosis actually holds his penis back and pushes it into his body. My question is about the language in my policy. It says that they do not cover the circumcision for the reasons above but that they do cover anesthesia and hospital rooms for all outpatient surgeries. Are we then only going to be responsible out of pocket for the cost of the urologist doing the surgery? In my mind and opinion, the urologist, the room, and anesthesia are separate and independent bills and therefore we should be able to claim them as covered costs but I am not sure. I am hoping someone who reads this is versed on this and can provide the answer for me. I will still check with my insurance company but I have completely lost faith in them after this pre-approval fiasco. Thanks everyone. know that phimosis in infants is a very debated topic and I have researched the topic and chose my doctor based on his merit. Unless there are doctors posting here who have substantial evidence that infant phimosis does not exist, I will continue to rely on my doctor because he has substantial evidence to prove that it does occur.
9 months ago - 5 answers
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Generally, if the surgical procedure itself isn't covered, then none of the associated charges are covered (hospital, anesthesia, etc.). I currently work for a large hospital system, and we do quite a bit of business with United Healthcare. Additionally, I used to work for a large insurance company (not United). Based on my observation and experience, I'd say with 99.999999999% certainty that the anesthesia and hospital charges will not be covered also. When it says that "anesthesia and hospital rooms for all outpatient surgeries," it means *covered* surgeries. Any general benefits discussed in your policy refer to *covered* services. (And there should be language to that effect somewhere else in your policy...for example, under "exclusions," "limitations," or some section like that.) Both the hospital and anesthesiologist claims filed with the insurance company will include the surgical code that states what type of procedure will be performed. So, essentially, their claims will be billed as "circumcision" also. Regarding whether or not your policy will and/or should cover the circumcision...its hard to say without seeing your exact policy. Its possible that you have a specific exclusion for circumsisions except during the newborn hospital stay. (If I were at work right now, I try looking up UHC's standard procedure for circumcisions just to see what it says. But, even then, the "general" way they handle circumcisions wouldn't help if you had a policy-specific exclusion.)
Source(s)
15 years working for health insurance companies and medical providers
by sarah314
9 months ago
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Other Answers
As it stands now, you will responsible for the full cost of the urologist. Since the decision from the company was that the operation was elective, out-of-pocket does not apply. As you note, they will cover anesthesia and the operating room expense. You have two options. First, you can appeal the decision from the insurance company. Do this immediately. Many companies have very strict time frames for appeals. Follow the appeals procedure to the letter. Also, get a letter from the pediatrician as to why the surgery had to be postponed and why it is necessary, not elective at this time. Second, you can pay the urologist yourself. If you offer cash/check, I would suggest hat you can negotiate with the urologist. Point out that you deserve a discount since he won't have to deal with the insurance company, that he is already providing the insurance company a discount and his price should start there, and by dealing in cash, he doesn't tie up one of his employees to fill out forms, track payments etc, thereby saving him money. In regards to the appeal, deal as directly as possible with the office/employee handling the appeal - try to avoid going through the customer service phone line.
by Steve D- 9 months ago
You seriously need to get a second opinion from a different doctor. Phimosis at birth is impossible and often a misdiagnosis for something that is perfectly normal. The foreskin is not usually retractable at all until 3-5 years of age, and not fully retractable until 10 years, so your 8-month-old is healthy! Even if your son does have some degree of phimosis, applying a topical steroid cream would be an effective nonsurgical treatment. This treatment is actually recommended over circumcision by the Australasian Association of Paediatric Surgeons. A Spanish study a few years ago found 90% of phimosis cases were successfully treated by steroid creams.
by Michael- 9 months ago
Consult a foreskin-friendly doctor for alternative treatment and leave him intact. It will save you a fortune and he will be better off too. The phimosis is probably not real. Most diagnosis of phimosis in infants is wrong. Contact NOCIRC for help in getting a second opinion. www ... Geoff
by GeoffB- 9 months ago
I thought everyone started with phimosis. The foreskin is normally tight against the glans at birth and for the first few years, and that's not a problem. Just let it develop normally and it'll loosen by the time he hits puberty, he'll be fine. Many American doctors think the only thing you can do with a foreskin is cut it off. Their schooling simply doesn't go into much detail about the proper functioning of a healthy, intact penis because they used to be so rare here. With people realizing (finally, only a century late) that circumcision is snake oil, we're finally joining the rest of the civilized world in abandoning the procedure. Circumcision rates are falling, but doctors aren't keeping up. Get another doctor to check him out, preferably one who trained in Europe. I bet the second opinion finds that there's nothing wrong with your son at all.
by skinman- 9 months ago