Any insurance advice?


New Member
Hi All -

The good news: I have a consultation with the surgeon in Raleigh, NC who performed Kyle's cleft lift a couple of weeks ago in June! [:8)]

The not so good news: I have no idea how to go about getting it paid for. I work for a state University, and so have a generous insurance package. I have, however, read that many people encounter problems because the cleft lift is considered a "cosmetic" surgery. [:^]

Here's my question...

Has ANYONE out there gotten cleft lift at least mostly covered by insurance? If so, how did you go about convincing them that this is not at all cosmetic?

I've considered going through the proper channels to prove that, in the end, so much more time off work, home health care to handle dressing changes (I'm single and live alone) for any length of time, etc. would be more costly... But has anyone done this?

Thanks for any input!



Very Helpful
Our insurance covered all of Jared's except our deductible......

We have Highmark Blue Shield here in PA, and I was SO worried they wouldn't cover it.... for two reasons, one is that it is a relatively new surgery and some insurance carriers consider it "experimental" or "cosmetic"...secondly is that we put my son on his dad's insurance only ONE MONTH before we scheduled the surgery, so I worried that they'd throw the "pre existing clause at us".....

But all went smoothly, they paid all of it but our 500 dollar deductible. No questions asked.

Have you asked your insurance carrier about whether they'll cover it, and HOW they go about deciding what to cover and what not to cover? I should think that a form of some type, prepared by your doc, explaining the disease and how this surgery works should be enough to convince them to cover it if they have any doubts about it being a medical rather than cosmetic procedure. Then again, some carriers are notoriously stubborn, as in the case of that girl some time back who needed a transplant procedure and the insurance carrier refused to pay for it and she died while her parents were trying to convince them of the necessity of it. Well..hopefully the lawsuit that is sure to follow will scare other carriers into being more lenient and accepting of new procedures.

Just wanted to add; CONGRATULATIONS on your upcoming appointment. Kyle's case seemed very very extensive, we all saw the pics, and we were rooting for him. It is such good news to hear he recently drove for the first time since his successful surgery and felt no pain. Seeing his pre surgery pics and hearing the good news he recently posted is SO great.....

And so is reading that someone else is taking that step!!!!

Kyle S

New Member
rgurl, my surgery w/ Dr. Faust cost $17,000, but we only paid $1,100 out of pocket. We do have great insurance since my dad is a dept. head at the hospital here. I seriously doubt you will have issues with it being considered cosmetic surgery.


New Member
Hi to the forum. :) My 17 yo daughter we just recently diagnosed ... had an abscess lanced and has 4 pits! We live in CT so we can pretty much search the tri-state area for any surgeons.

Insurance can be a tricky thing. I have a Cigna open access plan which is pretty liberal. When I searched for a a surgeon I came across a Dr. Gorfine in NYC that does the Cleft lift. However he is NOT in plan. So that means a $500 deductible right off the bat. PLUS since he is out of plan, insurance only covers 65% of the surgery. Here is the kicker...the one and only Dr Bascom in Oregon is IN my plan and other than a $20 deductible is FULLY covered! and with flights out to Oregon at nearly $500 per ticket it's just crazy! [:^]

We have scheduled a surgery with Dr. Soni in Danbury, CT. He is a plastic surgeon. His office explained that Cigna covers because of the Advanced Pilonidal Disease diagnosis regardless of WHO performs the surgery. While my first choice would have been Bascom or Gorfine performing the surgery..This Dr. is fully covered by my insuranceand has totally listened to every question and concern I have had. Sometimes we have to do what we can afford! At this point the dr. does not know if it will be an open healing or flap surgery...he says that he will knwo more when he opens it up.

Hopefully your insurance will cover this based on the diagnosis rather than the actual Dr. performing it! Sorry to ramble...hope this helps!


New Member
Thanks to the three of you for your replies!

I have not asked my insurance carrier yet. I did speak with the insurance/office manager at the surgeon's office - she's the one who agreed to set up a consultation for me with Dr. Faust WITHOUT a referral. :D (I'd been going back and forth to my regular doctor and have had 3 different opinions in the past month - none of them seemed to even know what they're looking at!)

Jaredsmom - it is awful what happened with that girl and the transplant... and so sad that SO many things like that happen and never even surface.

A deductible would be one thing, but paying much more than $500 to $1,000 would be close to impossible for me at this point. I'm currently experiencing the joys of a mound of student loan, etc. debt from college. [=(]

Kyle - thank you VERY much for the detailed reply. I am pretty much counting the days until my consultation with Dr. Faust. I plan to go to the appointment with a laundry list of questions. The most frustrating thing about all of this (for everyone, I'm sure) is that it seems nearly impossible to get STRAIGHT answers and solutions from anyone in the medical field. (Except, of course, Dr. Bascom!)

JessisMom - interesting that the diagnosis itself is what got you through some red tape.

Thanks again for the input!!!


New Member
one thing I know for a fact that you do not have to worry about is this"pre existing clause at us" they did away with that.

Also for the best answer call your insurance and find out. They can be very helpful.

Also just for a FYI I can get mine covered just found out the wrong ICD-9 code was sumitted (the one they submitted was for a Butt lift) so now I can see why they declined it.

Also another FYI someplaces do not make you pay the deductible first. last operation I had I paid over a few months afterwards. Something to look into.

Jessismom can you PM the phone number to that doc. I am in Watertown CT not far from there and my in-laws live in Bethel that is much closer for me to go to.


New Member
Thanks Mike...

I've held off on calling my insurance company until seeing the surgeon for a consultation - that was the advice of their office manager... so we'll see. (But don't worry, I do plan on having a very detailed convo with them! ;))

I suppose I am interested at this point to find out different ways in which folks successfully approached their insurance carriers.

And WOW - they seriously submitted that as the name of the surgery? Geez. I guess that whole bit about dotting your "i"s and crossing your "t"s gets to be pretty important after all. That is one thing that's worth a chuckle...



New Member
Thanks for the info,

Also they bill and submit under what is called CP4 and ICD9 codes kind of like this 169.9 it is code and they made a typo under mine. i found out from my wife that they submitted a butt implant and butt lift. That is why they declined it. Once that was cleared up I am good to go. but I am now thinking of changing doctors to the ones in Danbury. but I will need to speak with them as well.


New Member
Hi there-

Did you find out what the proper code is for the cleft lift? I am trying to find out what my insurer (GHI) will cover but they won't tell me anything without the code....



New Member
Mike - besides the code, can the insurance company tell you what your actuall out of pocket costs will be ahead of time? I don't mean what your deductible is and what percentage of the charges you will pay, but the actually dollar amount? I've never had luck trying to get this info out of my insurance company (UHC) in the past, so that's why I was thinking maybe doctors charge different insurance companies different amounts for the same procedure and that is why the insurance can't/won't tell you in advance. Maybe your wife knows how this works, since you said she works at your insurance company?


New Member
I used to work for an insurance company, for 8 years so I have experience with dealing with them. First, there is a pre existing condition clause still in insurance. Most HMO plans don't have it but most PPO, Open Access plans still have it. Believe me, they didn't do away with it. Second, and most importantly, stay in network! This will save you so much money, it's not hard to find a surgeon in network. I had my surgeries more than 5 years ago and had no problem with the cleft lift being done. It wasn't considered cosmetic or experimental so I'm not sure where that was heard. The surgeons I used have been doing it for years.

I highly doubt that the insurance company will be able to give you a cost of how much this will cost you to the penny. Surgeon fees, OR fees, etc..very from town to town. They can say your dedcutible is this, your coinsurance is this so we expect that it will cost you this much, but they won't be able to give you a complete breakdown, it's almost impossible.

Insurance coverage can be tricky, most people think they only have to pay their deductible and then the insurance pays everything else, it's a shock when they get the bill. Feel free to contact me if you have more questions.


New Member
Also yes if the Doc is in-network they will be albe to tell you what you will have to pay that is because you will only have to pay is your deductible. And if there is more costs they will be able to tell you that as well due to the fact that the Doc has a contract with the health insurance company for everything. They already know how much sometihng will cost.

Please for correct information contact your insurance company. Because just like taxes laws and rules for the health care industry changes yearly as well.


New Member
The Health Insurance Portability and Accountability Act (HIPAA), effective July 1, 1997, provides certain protections for people who have preexisting medical conditions. A preexisting condition is any medical condition that a person has before being enrolled in an insurance plan.
This law helps protect your health insurance benefits by:
  • limiting exclusion periods for preexisting conditions;
  • lowering your chances of losing your existing coverage or of being discriminated against because of your health;
  • providing protections for you when you change jobs;
  • allowing you and your dependents special enrollment rights under your employer's health plan under certain circumstances;
  • providing you guaranteed access to individual coverage through the Illinois Comprehensive Health Insurance Plan (ICHIP) if you lose your employer's plan and have no other coverage available;
  • guaranteeing renewability of individual health insurance coverage.
Preexisting Conditions

HIPAA limits the time you can be denied coverage for a preexisting condition under your employer's health insurance plan. Under HIPAA, an employer health insurance plan can deny coverage for a preexisting condition only if the employee or dependent is diagnosed, receives care or treatment, or has care or treatment recommended in the 6 months before the enrollment date. Note: Pregnancy cannot be denied as a preexisting condition by an employer's insurer. In addition, preexisting conditions cannot be applied to newborns, adopted children under age 18 or a child under age 18 placed for adoption as long as the child become covered under the health plan within 30 days of birth, adoption or placement for adoption, and provided the child does not incur a subsequent 63-day or longer break in coverage.
The length of time coverage can be denied for a preexisting condition under HIPAA is limited to no longer than 12 months (18 months if you are a late enrollee). This time can be reduced or eliminated if you were covered by previous health insurance (which qualifies under HIPAA as creditable coverage) and if there was not a break in coverage between the plans of 63 days or more.
You must enroll in the employer's health plan when first eligible; you may not be allowed to do so at a later date. If you are allowed to enroll at a later date, you will be considered a late enrollee and you may be subject to the 18 month preexisting waiting period. Note: There are special enrollment provisions which allow you to enroll later under certain circumstances which will be discussed later in this Fact Sheet.
Whenever you obtain health insurance coverage through an employer group, you should submit a "Certificate of Creditable Coverage" for each plan under which you were previously covered. Creditable coverage includes most health coverages, including COBRA, a health insurance policy or an HMO, Medicaid, Medicare, the Indian Health Service, TRICARE, the Peace Corps, a state high-risk pool (ICHIP) or a state or local governmental public health plan. You should receive a "Certificate of Creditable Coverage" whenever you lose health coverage for any reason. If you do not receive one, you may request it from the insurer. If you are unable to obtain a "Certificate of Creditable Coverage," the new employer sponsored health insurance plan should accept other proof of coverage such as pay stubs showing payroll deductions or canceled premium checks.
The new plan will give you credit for the time you were covered under previous health plans so that if you had at least 12 months of creditable coverage without a significant break (63 days or more in a row), no preexisting condition exclusion can be applied to your new coverage.
Note: CREDITABLE COVERAGE DOES NOT APPLY when you buy INDIVIDUAL HEALTH INSURANCE, with the EXCEPTION of HIPAA CHIP. If you buy individual health insurance, you will be required to meet specified time requirements (up to 24 months) prior to benefits being paid for preexisting conditions.
Example 1: You were covered by an employer group plan for two years before leaving your job. You acquired coverage under your new employer's group plan; however, there was a break between the two plans of 45 days during which you had no health insurance. Since the break in coverage did not exceed 63 days, the new insurer must credit you for two years of coverage and cannot apply a preexisting condition limitation.
Example 2: You were covered by an employer group for 7 months before leaving your job. You acquired new coverage under your new employer within ten days of losing your old plan. The new plan must credit 7 months to the preexisting condition limitation, leaving you a maximum of 5 months during which those conditions may be limited or denied.
Example 3: You were covered by an employer group for three years, at which time you lost your job and insurance coverage. You did not get a new job or insurance until 6 months later. Since you had a break in coverage which exceeded 63 days, preexisting condition limitations may be applied under the new plan.
Protection Against Losing Existing Coverage

HIPAA defines a "group" as an employer group of two or more employees. Under the law, all employer groups must have the option of renewing coverage with the insurer and coverage can only be canceled in certain instances.
HIPAA defines a "small employer group" as a group of 2-50 employees. An insurer cannot refuse to sell to small employers (if the insurer sells small group coverage) and must cover all employees and dependents, regardless of health conditions, who are eligible under a small employer's plan.
Protections Provided When Changing Jobs

As stated earlier, preexisting condition exclusion periods are now limited under the new law. This allows workers to change jobs without being penalized for existing health conditions by their new employer sponsored health insurance plan. When you change jobs, you must be allowed to enroll in the employer sponsored health plan, regardless of your health conditions, if you enroll when first eligible.
It is important to note that HIPAA does not require employers to offer health insurance to employees. Your new employer may not provide health insurance coverage at all, or the benefits may differ from your previous employer's plan.
Your new employer may have a waiting period before benefits begin; however, this waiting period is not considered a break in coverage when determining continuous coverage.
The cost of health insurance may also vary from employer to employer. HIPAA does not set any cost guidelines for premiums. However, you cannot be charged more than other members of your group because of health conditions.
Special Enrollment

Insurers are required to provide for special enrollment periods during which certain individuals are allowed to enroll in the plan even if they did not enroll when first eligible.
If you did not enroll in your employer's health plan when you were first eligible because you were covered under other insurance, you may enroll under a special enrollment period if you lose the other coverage. You and your eligible dependents must be allowed to enroll if you apply within thirty days after loss of the other coverage.
You may also enroll under a special enrollment period if you get married, have a baby, adopt a child or have a child placed with you for adoption. You, your spouse, and your dependent (through birth, adoption or placement for adoption) may be added to coverage under special enrollment if you apply within thirty days of the marriage, birth, adoption or placement for adoption.
Guarantee Access to Coverage When You Lose Group Coverage (HIPAA CHIP)

If you lose your group coverage, including expiration of your COBRA or Illinois Continuation Coverage, and you have no other coverage available, you may apply to the Illinois Comprehensive Health Insurance Plan (ICHIP). ICHIP offers the HIPAA CHIP plan for individuals who have lost their group coverage and cannot obtain other health insurance coverage through a group or individual policy. HIPAA CHIP has no preexisting condition exclusions.
To be eligible for HIPAA CHIP, you must:
  • be a resident of Illinois;
  • have at least 18 months of creditable coverage;
  • have most recent creditable coverage provided under a group plan, governmental employee plan or church plan;
  • not have a lapse in coverage of more than 90 days since you lost your group plan, governmental employee plan or church plan;
  • not be eligible for coverage under a group plan, Medicare Part A or B, or Medicaid;
  • not have committed or attempted to commit fraud in obtaining insurance or benefits;
  • have exhausted continuation coverage under COBRA
Renewability Of Individual Health Insurance

For individuals covered by an individual health insurance policy, HIPAA prohibits an insurer from canceling or nonrenewing the coverage. An insurer may only nonrenew or discontinue an individual health policy for (1) nonpayment of premiums; (2) fraud; (3) termination of all its individual coverage in the market; or (4) loss of membership by the individual in an association under which the coverage was purchased.


New Member
Chapter V.
Your Rights to Coverage of Preexisting Conditions

[FONT=verdana,sans-serif]SUMMARY OF YOUR RIGHTS
  • If you are joining a group health plan, You have the right to not be denied coverage on the basis of your health status, medical condition or history, genetic information, disability or insurability.
  • You have the right to receive coverage for preexisting conditions in most cases within 12 months (or, in some instances, 6 months) of enrolling in a health care plan.
  • If you are enrolling in an individual plan, you have the right not to be denied coverage if you have had 18 months of continuous coverage previously and meet certain other requirements.
  • You have the right to be credited for time enrolled in a previous plan against any preexisting condition waiting period.
  • [/FONT]
In 1996, Congress passed a law known as the Health Insurance Portability and Accountability Act or HIPAA (also known as the Kassebaum-Kennedy Act), which went into effect on July 1, 1997. HIPAA was designed to allow employees to move freely from one job to another without the risk of becoming uninsured for their most serious health problems. HIPAA also has protections for individuals who move from group plans to an individual health plan. In California, there are additional protections for members of group health plans that go beyond the requirements of HIPAA.


New Member
thank you for the information on HIPAA, if you read it carefully you will see that if you had coverage for more than 18 months and switch insurance there is no pre existing clause, provided you get proof from your insurance carrier. If you have no coverage, or have gone more than a specified amount of time the pre existing condition clause will come into play.

In addition to your deductible you can also have a co insurance, if you have a 90% plan you have to pay 10% of the cost after the insurance pays 90%, so no, the only thing you pay isn't the deductible. If you have an 80% plan you have to pay 20%. That can add up.

*by the way I just left the insurance industry about 4 weeks ago so I do know what I'm talking about :)


New Member
Well, double hallelujah, we seem to have found a surgeon for Jasper in network who does cleft lifts! We are seeing her tomorrow....fingers crossed, it would really solve a lot of problems. (business is SLOW these days..)


Very Helpful
Our insurance really did only bill us for the deductible....

they didn't hassle us about the procedure either....

AND we enrolled my son ONLY ONE month before we scheduled his surgery....

Even though the coverage takes a bite out of my hubby's paycheck, it seems to be worth it considering that this seems to be a pretty hassle free insurance company. By the way, we have Highmark Blue Shield, here in Pennsylvania.

Doug, congrats on finding a cleft lift surgeon for Jasper. He's so young, and it is a shame he has to deal with this crappy disease, it's a shame anyone has to.... but you will not regret cleft lift. He'll be sitting a drumming his heart out in two weeks....

In my opinion, and the opinion of those who've had it done....we all say, we wished we'd done it sooner.


New Member
Country flag
As someone that had amazing insurance (worked for state government), who had to pay for the Cleft Lift procedure out of pocket... I can not stress enough how important it is to do your homework before your procedure. My insurance company declined my original pre-op request for coverage. Due to my poor quality of life and how much discomfort I was having, I chose to have the surgery. Following my surgery, I battled with my insurance company for 11 months, before I exhausted all of my options and paid all of my outstanding balances out of pocket.

Do your research, make sure you know what the real cost is and if your insurance will cover this procedure. It was totally worth it, but it sure made a dent in my savings!

Kyle J.