Out-of-Network Reconstructive Surgery

Hi!

I have Anthem health insurance (Anthem Silver PPO 50/1700/40%) and I need some help.

I am transgender and am planning on getting top surgery, which, according to this Anthem link, is a reconstructive surgery. No one near me offers it in a timely fashion, so I was planning on going to a place out-of-network to get the surgery. Before today, I was planing on paying entirely out of pocket without even considering insurance, but I realized that insurance can help pay for some of this, so I reached out to the insurance company.

If the surgery is considered medically necessary, then I would pay my $3400 out-of-network deductible then 50% coinsurance until the Anthem limit, then I pay for everything else until the maximum out-of-pocket is reached, for the procedure.

But the aforementioned link refers to the bilateral mastectomy/top surgery as reconstructive versus the medically necessary category it places onto other options, yet later it does call that specific surgery medically necessary when discussing criteria being met (which, for me, all required criteria are met!).

Does that mean that it won't be considered medically necessary and insurance won't help me out at all? Will insurance still help me out if it is considered reconstructive?

Thank you so much!

submitted by /u/Pink_Pin3appl3
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