AboutJohn Pedit Expertise Am an expert on Medicare, Medicare HMOs, and Medicare supplemental insurance. Also have extensive knowledge of Medicare especially in Mich. Have knowledge of COBRA and the Portability Act
Experience
Past/Present clients Council about 300 persons yearly and do many presentations on Medicare
Question If a woman has breast reconstruction after a mastectomy for breast cancer, does her managed medicare plan have to cover the surgery? If so, is the managed Medicare plan allowed to require a pre authorization for the surgery or allowed to deny the procedure for no authorization or as not medically necessary?
Answer Hi Diane
The doctor is the one that makes the decision if it is medically necessary and assigns the proper codes. The HMO can require pre-authorization and will not pay the bill unless this is done(other than an emergency). Will also deny if the codes used do not indicate it was medically necessary.
