Health Insurance

PATIENTS WITH HEALTH INSURANCE

For insured patients, Mr Gault’s consultation fees, surgical fees and follow-up fees are normally covered in full by some insurance companies (WPA, PPP and Pru Health for example). Many insurers have recently reduced the level of reimbursement, however, and BUPA and Aviva members in particular should be aware, that current reimbursement may be less than with other Insurers, so there may be a shortfall which is payable by the patient. PPP (Private Patients Plan) members should be aware that PPP sometimes do not pay for follow-up fees within ten days of your surgery.

There may also be an excess on your policy, or specific exclusions. Surgery for aesthetic (cosmetic) reasons is usually excluded, for example. Laser treatment to treat difficult verrucas or pilonidal sinus may not be covered, nor laser treatment to reduce the amount of tissue which must be removed when excising cancer. You will be asked to settle any shortfall and we strongly advise that you check that you have authorisation from your Insurer for the procedure you contemplate together with benefit maxima. Your insurer may ask you for a CCSD code to indicate to them the type of procedure you are considering, and we are always happy to help.

Please also be aware that an authorisation code does not necessarily mean that an insurer will pay the fees for a procedure.  If there are any doubts, ask your insurer to let you have confirmation of the terms of the authorisation in writing and we will be pleased to examine it.

 

HEALTH INSURANCE FOR EAR RECONSTRUCTION

The applicable CCSD codes for ear reconstruction include: D0310 ear reconstruction including graft, T0320 Exploratory Thoracotomy, T0810 Resection of Rib, S3620 Full Thickness Skin Grafts and S2400 Large Local Flap). However, there is no code for multiple complex Z-plasties, carving of the cartilage framework from rib segments, nor for framework assembly, which doubles the procedure time.

Many insurance companies, such as BUPA, PPP, and WPA have designated the procedure of special complexity, to enable reimbursement of fees in full. We would emphasise, however, that such authorities are awarded on a case-by-case basis, and are often strongly resisted by certain Insurers.

There may also be an excess on your policy, or specific exclusions. We respectfully request that you settle the fees in full pre-operatively and request reimbursement from your Insurer, if applicable. For detailed information on the surgical procedures involved, we recommend that your insurance company advisors consult the following seminal texts:

  • Rib graft reconstruction vs Osseointegrated prosthesis for microtia: A significant change in patient preference. Gault DT Clinical Otolaryngology. 2001, 26, 274-277
  • Reconstruction of the ear. Gault DT. A chapter for Principles and Practice of Head and Neck Oncology Editors Peter Rhys Evans, Patrick Gullane & Paul Montgomery. Martin Dunitz 2003 Winner of George Davey Howells Memorial Prize for most distinguished published contribution to the advancement of Otolaryngology during the preceding five years.
  • Management of Congenital Deformities of The External And Middle Ear. Gault DT A chapter for Scott Brown's Otorhinolaryngology, 7th Edition Arnold 2007.
  • Total Reconstruction of the Pinna - a chapter for Scott Brown's Otorhinolaryngology, Head and Neck Surgery, 7th Edition Arnold 2007

 

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