In my twenties, I had facial reconstruction surgery using tissue expansion and I had an individual policy with GHI. Like you, the hospital was included in my plan, but the doctor was not. To answer your question about anesthesia, it should be billed separately and will be administered by a participating doctor, due to his affiliation with the hospital. Prior to my surgery, the insurance carrier agreed this was reconstructive and they would pay benefits per the contract. The night prior to admission to have the tissue expander put in, I received a call saying there was a change and it would no longer be covered. Since there was nothing that would stop me from having the surgery, I told the representative to send me the decision in writing and had the surgery the next day. Eventually, I contacted my state insurance board and they did the rest for me. When all was said and done, not only did they cover me, but they paid the entire cost of both surgeries for the tissue expander and several surgeries for “touch ups”. After dropping them, I switched to Blue Cross Blue Shield and have had no problems with coverage.
Here are a few things you need to know. First and foremost, you must use “birth defect” and “reconstructive surgery” when addressing insurance companies. Secondly, most denials can be eliminated by checking with the doctor’s office to be sure the billing codes they are submitting to the insurance company are for reconstructive procedures. Third, the insurance companies use a “schedule of allowance” to determine benefit amounts. Since conditions such as these are not common, most times there is no schedule for such procedures and you need to ask for a “case manager”. Lastly, most insurance plans have a catastrophic allowance”, which means that once you pay out a pre-determined amount per your contract, the rest of the heath care for that year is free.
If you need any information, please feel free to contact me and good luck