Any insurance advice?


Staff member
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Keep the good info coming, gang. I'm going to sticky this post because the information is so critical.

I'll rewrite the insurance page on the site as well with all your tips.


New Member
Kyle J -

Question: was Dr. Bascom (who you ended up going with for the procedure) an in-network provider for your insurance?

Dr. Faust, who's doing mine, is definitely in-network. This is what I'm hoping will be my saving grace financially... [:xx]

I've read your personal story, and WOW. It's amazing everything you went through and how much this surgery - regardless of cost and being "off the beaten path" so to speak" - has changed your life. Thanks for sharing everything you have.

- Kali



New Member
My insurance experience.

Okay people I have blue cross blue sheild a pretty decent level through a small company. I had the cleft lift procedure out of state with a provider that was in the network list. I did not seek preapproval or ask any questions before the surgery (I wanted to get it done, once they do it they can't take it back!)

So I finally got my bill. My procedure was an outpatient procedure. The total bill submitted to my insurance was $15,812. roughly 8 thousand of that was OR time, about 3,200 of that was the general anethesia, about close to 2000 was charged for the recovery room and the rest was for in general medications and medical supplies (like the IV, the glue for the wound, antibiotics etc... )

My insurance apparently accepted the charges, I have a 1000 deductible and my co-pay has come out to about 1000. So all in all it will end up costing out of pocket about 2 grand.

Hope this is helpful.


New Member
Not trying to be hysterical


Had the cyst removed 4 or so years ago - w/out insurance. That was a pain enough (and I have a judgment against me because the hospital was supposed to wait for payment and didn't).

So the wound never really healed - and it seems like Cleft Lift would work great from these stories. I haven't had insurance until now - and I have two choices. One is a school insurance and they've already told me they doubt it would be covered. The other is a BC/BS plan through my job (so pre-exist conditions are covered).

Here's my question - Could I call BC/BS to ask the hypothetical before I sign up or do I have to have a policy? i have to decide on a policy by Friday (at the very latest) so I'm feeling rushed. I, obviously, can't afford 15-17K for a surgery but could do 2K - and I'm tired of having to hide my pants because of stains.


ETA: Highmark Blue Cross/Blue Shield seems to be the company through which our insurance will run if I get it through my work. I'm wondering if I should go ahead and sign up with them and figure it out. They're 1200 more a year than the college insurance but if they cover this (and the college doesnt), that's a HUGE savings.

Mr. Nurse

New Member
Here's what I would do (which is just my opinion, and there are probably better ways to do it). I would call just to make sure. Then I'd see a surgeon who performs the cleft lift to schedule the operation. You'll probably have to wait a little bit before actually having surgery. Hopefully your policy will confirm that the procedure is covered and won't have to worry about it. However, if for some reason it doesn't, then you can cancel the surgery. Can't you go online and look at the policy? My wife's insurance (on which I am a dependent) information is all online. We don't receive anything on paper. Good luck!


New Member
cleft lift costs

Well, I think all my bills have finally come in from the cleft lift for my daughter in July.

Hospital $5,521 (my portion to pay $1,1064)
Anesthesia $830.00 (insurance is still processing)
Cleft Lift $2,416 (insurance is still processing)
Doctor visit with Bascom before surgery $349.00 (insurance paid all)

Total before insurance = $9,116

I'm getting an itemized statement from the hospital to double check what they are charging us for. The insurance could only tell me what they charged for the semi-private room, which was $1466.51 for one day. So curious what the additional $4000 dollars is for :confused:

My UHC insurance in general pays 80-90% of the costs for procedures,etc., after they hold the providers to their contracted rate. My portion of our bills my be around $1700 (but added to that is the cost of our trip out there - around $1500). It is definitely better than having to pay for the complete medical costs, or a higher percentage - I'm grateful for that! But it is interesting, and frustrating, to see the costs vary so much from doctor to doctor!

I am so relieved that my daughter is healed, so the cleft lift was definitely worth it. Just wish I had the bucks to pay the bills without a worry, though :eek:. I tried to find out the costs before hand, and Bascom's office told me right about the exact amount they are billing. I never thought to call the hospital or any body else :(, and don't know whether they'd tell you much ahead of time anyway.

For others, if money is an issue as it is with most of us, I would suggest that if your doctor is planning for you to spend the night in the hospital, consider asking him/her to allow you to go home (or to the hotel if you are from out of the area as we were). Not staying at the hospital could drop costs quite a bit. Many people here have been able to go home after the cleft lift, so it's worth talking to your doctor about.


New Member
Wow, that makes me think the out-patient facility must have way overcharged for my pit-picking. The total for that was a little over 16k! Seems like it should be half of that if even.

I also have UHC and they are either still processing or disputing one of the charges labeled "MISC OP" that was priced at 6500. I have a feeling there must have been some kind of clerical error. I'm waiting to receive an update or something. That amount simply cannot be correct.

One thing that stands out is that on the form for the surgery, the surgeon wrote both bascom procedure and unroofing, when the bascom procedure kind of includes the type of unroofing that was performed. Wonder if that could be it?

If they give me trouble, I'm hoping the HR people at my work can help push back, as I work for a large company.



:rolleyes:Well in my state I have badgercare or ma and everythings been covered even down to the gauze,saline and tape. I wish there was a great solution for all of you. I can't even fathom insurance not covering an illness such as this!:eek:


New Member
I thought I would pop some information in here for Australian readers.

I have my private health insurance through NIB, but unfortunately the level of cover I have will not cover me for any procedure involving Pilonidal Sinus (I only have very basic cover in order to save tax as I don't have to pay the Medicare surcharge)

I am however still going to go through the private system and have today received my costings which total to $2084.00 out of pocket with Medicare picking up $480.00. Thats for day surgery in a private hospital and all fees associated with a closed Pilonidal procedure.

I thought that was fantastic for a Private hospital, the surgeon also gave me the option to go onto the public wait list in which I would have no out of pocket amount, but I'd prefer just to get it over and done with rather than have to wait 3 to 6 months (especially as I'm getting married in January)

Sweet Rogue

New Member
Does anyone have insurance info for an open excision? Like what it costs? I should be getting mine soon, but I'm a little nervous to see it.

Disco Dan

New Member
Do you not get free health care from the state in America?

There is no need in New Zealand to have health insurance, the state pays for all surgery and sends out a nurse every day to your home to change the dressings until it is healed.

How does the system work in the US?

Good luck with getting it payed for!! That is last thing you need to be worrying about after surgery.

Sweet Rogue

New Member
Nope- I wish we did. No, we either have to have insurance through our employment or have to get it ourselves, and we have to pay monthly to be covered and then if/when we have to go to the doctor if what we are going for is covered under our insurance plan usually only about 60-80% of the cost is covered and we are responsible for the rest.


New Member
Its for free in Australia as well, but you still have the option to take out "private" health insurance which covers you if you wish to have procedures done through the private non government owned hospitals.

I pay for private as going through the public system can mean long wait times.

Disco Dan

New Member
Sweet Rogue;63008 said:
Nope- I wish we did. No, we either have to have insurance through our employment or have to get it ourselves, and we have to pay monthly to be covered and then if/when we have to go to the doctor if what we are going for is covered under our insurance plan usually only about 60-80% of the cost is covered and we are responsible for the rest.

Your kidding??

That is shocking!

We have ACC - Accident Compensation Corp, which if your injured at work not only pays for injury but also pays you 80% of your wages while your off work - however long that may be.

This does not cover PC as it is not an accident but the public health care system pays for everything except wages. There is then a government organisation called Work and Income which then pays up to $300 per week for a sickness benefit straight into your account while your off work.

I have no idea how much surgical procedures would cost - as you do not even hear that side of things.

I am curious though - what sort of cost are we talking about here?

Good luck with your insurance! I certainly wont be moving to America!

Sweet Rogue

New Member
Sweet Rogue;62978 said:
Does anyone have insurance info for an open excision? Like what it costs? I should be getting mine soon, but I'm a little nervous to see it.

In answer to my own question- my open excision cost (including anesthesia, bloodwork, etc) aprox. $1,800
Here's my situation, maybe somebody can help me. I live in the US.

When my cyst first appeared (in 2004) I had no insurance. I had just been dropped only a couple years prior from my parents plan after reaching the maximum age limit. I tried getting my own stand-alone plan through several insurance companies but I couldn't afford the payments and they wouldn't cover my cyst anyway; as it was now a "pre-existing condition". And the only jobs that I have been able to get (not to mention the only jobs I am actually able to actually perform by standing up) never have any insurance plans. I currently work at a US Postal mail processing plant but was hired as just a "Casual" employee (how they hire most all new employees). They lay you off 1 week out of the year and then "re-hire" you so they can keep you on the books as a "temporary" employee and thus don't have to give you any benefits or rights; which means they can pay you a 1/3 of what they pay career union employees and work you as long or often as they want (I've worked 70 hours in one week before). It's practically impossible to get hired on as a "career" employee with benefits and union membership, and management has no incentive whatsoever to do so. To them it would mean that they would just have to pay your twice as much so you would work twice as less (because once people get in the union they practically can never be fired (unless they steal a truck full of mail or murder someone on the job) so once they get on as a career/union employee they slack way, way off and do absolutely whatever they want). It's an absurd workplace situation. You've got people working side by side doing the exact same job, only one is getting paid 2 or 3 times more than the other and doing half the work (if they happen to even be at work that day as they call in and take paid sick or vacation days every other day). On top of that the career union "regulars" are always filing "grievances" with the union and often end up getting paid for the work you're doing because of all the ridiculous little union rules. At any rate, what I mean to say is that I have no real hope of getting hired on as a career employee within the next 5-10 years and thus no hope at getting insurance through my job any time soon; and I don't know what other job I could possibly get. I applied for Medicaid but since I'm not a child, over 65, or a pregnant female and since I am technically able to hold down a job that makes over $900 a month I am not eligible for any category of Medicaid and was denied coverage. What am I to do? I really, really want to get the surgery done but cannot in anyway pay for a $15,000+ bill even in monthly payments. I've lived with this cyst for almost 5 years now and had to have it lanced 3 or 4 times in that period, not to mention the daily constant frustration of not being able to sit down ever. I use a coccyx cushion on the floor at a coffee table leaning on one arm to eat meals and the same cushion in my car and another to lean way over on the arm rest when I drive to work. All other times I have to either stand up or lay down on my side or stomach on the couch or bed (and even then sometimes it gets sore). I even have my computer stacked up high so I can stand at it. It's hard to get in comfortable position to read or even watch TV. When you can't sit down or lay down on your back, you can't ever fully relax. It weighs on your psychologically. I get frustrated and depressed often. It impedes every level of your quality of life and vastly restricts all personal and social activities. Everything becomes a chore. I mostly stay at home in my apartment and don't even visit my friends or family anymore because I can't sit down anywhere when I get to their house and have to awkwardly stand up or lay down and am never comfortable. If anybody has any suggestions whatsoever as to how I might be able to pay for the surgery please let me know.



New Member
Makes me angry


I am just SO sorry to hear your story. [o+o]

I'm not from the US so can't help you in regards to the medical system there. Perhaps you can put a post up in the main discussions area where more members will see and (hopefully) respond. Listing your state/location may also help.

Which procedure are you hoping to get? Are you sure about the costings? $15,000 seems on the high side even for the US. :eek:

Surely there is some kind of avenue for ppl in your position to get help. Hearing stories like yours really makes me angry. :mad:

I truely hope that you get some helpful direction soon!

All the best,


New Member
Health care Insurance is a must in Israel too (from the government)! we pay around 9$ a month (you could also have ur own private health insurance)


New Member
Insurance question - out of pocket total?

Hi all,
I have insurance and am looking to have the pit-picking procedure done in Pittsburgh PA, USA. I know the doctor, the facility, and all that. Almost all doctors in this area are associated with hospitals (it's the major industry) and the particular building where their offices are are also hospitals. When I go to a doctor, the billing can come from the physician (where my insurance will cover it after a $25 co-pay) but also from the hospital (where I'm liable for more of it, without cap). I've talked to the insurance company, the medical center's pricing line and billing departments, and nobody can actually tell me where the billing will come from or how much it will cost, until after the fact. (They've even said just can't know until after the fact.) Has anybody else had this done here and where were your bills from?



Staff member
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For those who are hoping to get your doctor to learn Cleft Lift or Modified Kardakis but are having a hard time because the doctor isn't sure how to bill for it, below are the CPT codes for the procedure.

Your doctor's office will know what these are and what to do with them.

[FONT=&quot]11772[FONT=&quot] Excision of pilonidal cyst or sinus; complicated[/FONT][/FONT]
[FONT=&quot]14301[FONT=&quot](Cleft closure) Adjacent tissue transfer or rearrangement[/FONT][/FONT]