Once you’ve been diagnosed with trigeminal neuralgia, and medicine has not successfully relieved your pain, you may be referred to a neurosurgeon who can evaluate you for surgical treatments. For patients who are otherwise healthy, and where impingement on the trigeminal nerve is seen on imaging, microvascular decompression may be suggested to achieve relief. You may ask yourself, “Does insurance cover microvascular decompression?” Use this guide to determine your medical insurance coverage, and start walking down the road to recovery.
Evaluating Your Insurance Benefits – Working with a Benefits Specialist
Benefits specialists work within medical and surgical practices to arrange and coordinate appropriate insurance coverage for patients. These specialists are trained to understand how and what different insurance companies provide coverage for certain procedures and diagnoses. Your first step in asking the question, “Does insurance cover microvascular decompression,” is to meet with the benefits specialist at your neurosurgeon’s practice.
The practice’s benefits specialist can provide you with a lot of different information and support, including:
- What deductible you must meet before coverage kicks in
- Whether your neurosurgeon is considered in-network or out-of-network
- What percentage of the procedure’s costs will be paid by insurance
- What percentage of the procedure’s costs you will be responsible for
- What your out-of-pocket maximum is – the point where insurance will cover costs at 100 percent for in-network procedures
- What additional pre-qualification steps or documentation you will need to follow or provide
Determining Your Own Benefits
You may be interested in investigating your own benefits if you are waiting for the opportunity to meet with your neurosurgeon’s benefits specialist. The good news is that you likely already have a benefits coverage packet from your insurance company, or can obtain one from your employer’s benefits team, or can access one online. You can also call your insurance company directly and speak with a coordinator to determine your coverage.
You will need specific information during your query, including:
- Your neurosurgeon’s name and the practice name
- Tax Identification Number
- The CPT (insurance) code or codes related to your pending microvascular decompression procedure
- The diagnosis code being used for your trigeminal neuralgia and any related diagnoses
What If You’re Out of Network?
In the midst of determining whether your insurance will cover your microvascular decompression procedure, you may find out that your neurosurgeon is considered out of network. This status does not necessarily mean your insurance will not cover your surgery. It simply means you will need to spend time exploring how your specific insurance plan handles out-of-network claims.
A smaller percentage may be covered than with an in-network provider. You may also have a different deductible and out-of-pocket maximum amounts. In addition, your surgeon’s office may not file insurance claims with an insurance company that considers them to be out of network, meaning you’ll have to file your own claim.
If your coverage is determined to be out of network, you will need to make a decision: continue working with the neurosurgeon you’ve already gotten to know and who knows your case, or find a different provider who is considered to be in network. While you may experience cost savings by changing providers, you’ll also need to start over from scratch with a different neurosurgeon. It can take considerable time to get an appointment with another neurosurgeon, which means your treatment will also be delayed significantly. You need to determine whether you’d rather bear extra cost in return for faster relief, or whether you are able to wait and save money.
What If Coverage Is Denied?
At times, insurance companies may deny your pre-authorization request to cover your microvascular decompression procedure. This denial can happen for several different reasons, including:
- Your insurance policy not covering that specific procedure
- A determination that the procedure is not medically necessary
- A lack of supporting documentation to show why microvascular decompression is the correct procedure for your trigeminal neuralgia
Just because a pre-authorization request is denied doesn’t mean you won’t eventually get your insurance company to cover your surgery. First, you can appeal the decision. Your insurance company may allow you to begin the appeal process via phone or Internet, or you may need to file specific forms. You can provide additional paperwork that shows the progression of your trigeminal neuralgia, including the fact that medical management has not been successful. You can share imaging results to show your impingement. Your doctor can provide a statement defending microvascular decompression as the best choice to treat your trigeminal neuralgia. Additionally, you can obtain a second opinion to support the need to use microvascular decompression for your specific case.
Additional Opportunities
Many times, this additional paperwork can influence your appeal and result in your procedure being covered. In fewer cases, coverage may still be denied. However, you’re not yet at the end of the road. First, you may be able to work with your neurosurgeon’s practice to set up a payment plan; various types of financing may be available to you. Then, you may discuss opportunities with your neurosurgeon to investigate other procedures, like Gamma Knife Radiosurgery or the implantation of a nerve (pain) stimulator.
Microvascular decompression can spell significant or total relief for the pain of trigeminal neuralgia and other nerve impingement disorders. You may find that you’ll need to spend significant time with your practice’s benefits specialists, as well as representatives with your insurance company, to ensure that the correct coverage decision is made. You’ll have multiple opportunities to prove your case, and your perseverance can help bring a resolution to your trigeminal neuralgia.
