Lipedema surgery – BCBS TX – PreDetermination Approval – Claim denied for being cosmetic

Hi all! New to posting.

I had lipedema removal surgery for lowers December 2022. I called BCBS multiple times to verify benefits, try to file pre auth, etc. I got the out of network waiver approved because they could not provide doctors that provided my necessary service. I asked them specifically if there’s anything I need to do to make sure I’m reimbursed. They said no, just pay upfront, submit the claim, and cross my fingers. They wouldn’t ‘allow’ me to submit for pre authorization because it wasn’t required for the CPT code.

My first claim was denied because it was considered experimental/investigational. The first appeal was denied because I didn’t have the necessary requirements to meet the medical necessity. I didn’t have 3 months of therapies or show functional impairment. I went all the way through to external appeal and they had the same findings. After this was said and done, I called to verify what needed to be done. One of their reps finally told me that pre auth is different than pre determination. So I started over for my second claim.

I got my second surgery September 2023. Before surgery I got an extension to have my surgeon considered in network. I also got approval for pre determination. From my understanding this means I meet the requirements for it to be considered medically necessary. Fast forward to today.. the surgery has been denied because it’s considered ‘cosmetic’.

So help me understand.. they have a medical policy. I meet the requirements and submit documentation showing that. BCBS TX approves the request. They then turn around and call it cosmetic. How do I appeal this?

Info: my surgeon does not deal with insurance. He is the best in this country and I flew to him. BCBS could not provide me with any in network doctors to receive the treatment with.