Question
I had a mastectomy with reconstructive implants now one of the implants has failed my doctor wants to do latissimus dorsi flap, which involves use of a muscle and a 12" scar that will show in some clothes. My problem is I want a different type of reconstruction that my doctor doesn't do, and there isn't a doctor in the group that does that type of surgery does the insurance have to pay for that? if I go out of network.
Answer
Hi Lynda
First of all it has to be Medically Necessary. If the doctor says it is, you have a chance.
Then it depends on whether it is a commercial policy, or a Medicare Advantage plan.
Either way, you should request a determination and permission to go out of network because they do not have a provider in their network.
If you go out of network without that pre approval, you are responsible for the cost. Since they can treat the problem with their providers, you have a pretty weak case,
John
