My insurance does not require referrals. Also, my insurance company could not tell me whether they’d cover this or not until they received a predetermination of benefits letter from Dr. Haney’s office. In the end, my TAC surgery cost only my $100 surgical copay as I had already met my out of pocket max for the year.
Also, if you do not have insurance coverage, then you should consider contacting Dr. Davis’s office because he has a plan in place where he offers the TAC at cost – last I heard, this was around $4k. [UPDATE: that was when Dr. Davis was in New Jersey. I am unsure whether he offers the same cash price at his new practice in Tennessee.] I believe Dr. Haney was also working on something like this, but I’m not up to speed on that latest information.
This is a copy of information I received from Dr. Haney’s office:
Regardless of your insurance plan, you should immediately contact both your Primary Care Physician (PCP) and your insurance company to let them know that your surgery has been planned. Ask your PCP to fill out a referral form and submit it to your insurance company. The PCP will need the following information:
–ICD-9 codes: 622.5 (diagnose code)
–CPT codes: 58999 (procedure code)
–Anticipated length of stay: 23 hours
RE: EXPLANATION OF THE USE OF THE 58999 CPT CODE FOR PLACEMENT OF A TRANABDOMINAL CERCLAGE PRIOR TO PREGNANCY
The purpose of this letter is it to provide for the rationale for using the CPT code 58999 to describe the surgical procedure when placing a transabdominal cerclage for an incompetent cervix. The procedure performed is placement of a transabdominal cerclage prior to becoming pregnant. The CPT code utilized is a 58999, e.g., “Female Genital System Procedure”, which is typically used when describing an unlisted gynecologic procedure.
The ICD-9 code for an incompetent cervix when pregnant is 654.53 and 622.5 when not pregnant. The CPT code for placement of a transabdominal cerclage during pregnancy (typically between the 10th and 14th week of pregnancy) is 59325. There is no CPT code for placement of a transabdominal cerclage prior to pregnancy, hence the use of the unlisted “Female Genital System Procedure” 58999 CPT code. The procedure requires a laparotomy, spinal or general anesthesia, placement of a 5 mm Mersilene band immediately beneath her uterine arteries surrounding the cervix and an over-night hospital stay. The general risks are comparable to any gynecologic laparotomy for benign disease.
This should adequately explain the use of the 58999 CPT code when placing a transabdominal cerclage prior to pregnancy.
If your policy does not require a referral form from your PCP (most PPO’s do not), contact your insurance provider and inquire about pre-certification policies/procedures. It is vital that you follow all of your insurance provider’s guidelines. Failure to do so puts you at risk for having your procedure denied, and puts you at risk of being responsible for the bill. It is better to postpone the surgery than to have your insurance provider deny payment and send the bill to you because their administrative procedures were not followed. We are more than happy to help you to navigate through your insurance provider’s process, but ultimately we cannot do it for you.