Most practices will not put this in writing. The answer patients usually get is some version of we will check your benefits, which tells you nothing you can plan around.
So here is the whole picture: what actually happens, what insurance typically pays for, and what you would be responsible for. It is a lot to take in, and some of it is genuinely frustrating. Every part of it is easier to deal with now than after an operation.
What out-of-network actually means
This practice holds no contract with any health plan.
Out-of-network does not mean uninsured, and it does not mean your plan pays nothing. It means your care is covered, if at all, through your plan's out-of-network benefits rather than at a rate negotiated in advance.
Three things follow from that, and they are the ones that matter:
- Your out-of-network deductible is separate. It is usually higher than your in-network deductible, and money you have already spent in network does not count toward it.
- Your plan pays a percentage of what it decides the service is worth, not a percentage of what was billed. Your plan sets that figure.
- The difference between what was billed and what your plan pays is yours. You will know that number before surgery, in writing.
You are also free to seek care from a surgeon in your plan's network, and for common procedures that is often the right choice. For neurofibromatosis surgery, facial paralysis reconstruction, and cleft rhinoplasty, many plans simply have no participating surgeon who performs these operations with any familiarity, which is how most patients end up here.
What plans typically cover
The line health plans draw is between function and appearance. That distinction does most of the work, and it does not always fall where patients expect.
Neurofibromatosis surgery and insurance
Generally treated as medically necessary:
- Neurofibromas that are painful, bleeding, ulcerated, or repeatedly irritated
- Neurofibromas causing itching severe enough that scratching breaks the skin, and requiring regular anti-itch medication
- Tumors limiting movement, vision, hearing, breathing, or the use of a limb
- Plexiform neurofibromas that are growing, compressing a nerve or an airway, or causing pain or deformity
- Any tumor where malignant change is a concern
- Reconstruction following any of the above
Generally not covered: removal of small cutaneous neurofibromas that are not symptomatic, where the reason for surgery is appearance.
That last line is the one that lands hardest. A patient with hundreds of cutaneous neurofibromas is dealing with something that shapes every interaction they have. Plans routinely classify it as cosmetic. It is not a clinical judgment about whether the surgery is worth doing. It is a coverage category, and it is worth understanding as one.
Facial paralysis surgery and insurance
Facial reanimation addresses loss of function, and the functional consequences are usually well documented:
- Inability to close the eye, and the corneal exposure that follows from it
- Loss of oral competence, meaning difficulty eating and drinking without spilling
- Speech that is affected by the paralysis
- Synkinesis and involuntary movement interfering with daily activity
- Nasal airway obstruction from collapse on the paralyzed side
Lengthening temporalis myoplasty, selective neurectomy, nerve transfers, and static procedures are all submitted on that basis.
Where facial paralysis differs from neurofibromatosis is that the functional argument is usually stronger and better recognized. An eye that will not close is a documented risk to vision, not a question of appearance.
Cleft rhinoplasty, nasal reconstruction, and insurance
Nasal surgery is submitted on the basis of airflow and structure rather than shape. Findings that generally support medical necessity:
- Structural nasal obstruction
- Dynamic collapse of the internal or external nasal valve restricting airflow
- A deviated septum
- Sleep impairment and habitual mouth breathing
- Septal perforation
- A history of cleft lip or cleft palate
The same reasoning applies to nasal reconstruction more broadly, including local flaps and rib cartilage grafting, where the nose has been altered by a prior repair, by trauma, or by removal of a skin cancer.
Cosmetic rhinoplasty is not submitted to any plan. No plan covers it.
Pediatric plastic surgery and insurance
Being congenital does not by itself make a condition covered, and this is where families are most often surprised. Breast reconstruction for Poland syndrome, for example, may not be covered despite the condition being present from birth.
What generally is covered:
- Time-sensitive reconstruction such as cleft lip and palate repair and congenital hand surgery
- Conditions that would otherwise disturb longitudinal growth
- Injury and its reconstruction
- Certain vascular anomalies where there is functional impairment or bleeding
- Anything life-threatening, including airway obstruction and cancer
Timing matters in a way it does not for adults. A procedure that is straightforwardly covered when performed in the window where it affects growth or development can be viewed differently once that window has closed, which is an argument for asking early rather than waiting.
What actually decides it
Documentation moves a case from one category to the other.
Photographs, a specific symptom history, records of what has already been tried and for how long, and imaging all matter. Where a tumor is genuinely symptomatic or a paralysis genuinely impairs function, saying so in the record with specifics is what makes the difference. A vague note produces a vague determination.
Before your surgery is scheduled
Our office requests authorization from your plan for reconstructive procedures. Your plan decides, not this office, and approval is never guaranteed. Plan on days to weeks rather than same-week turnaround, which is a reason to start early.
You receive a Good Faith Estimate. Before a surgical date is held, you get the full expected cost in writing, listing every code that may be billed. This is a legal requirement under the No Surprises Act and it is also simply the right way to do it. You should never be surprised by the number.
A deposit holds your date. Twenty percent of the surgical fee reserves the date and is applied toward your fee. The balance is due ten days before surgery.
We bill your plan after surgery. Whatever your plan does not pay is your responsibility, at the figure you were given in advance.
Consultations and superbills
A consultation is $250, paid when the appointment is scheduled. The fee is the same in person or by video.
For reconstructive care you receive an itemized superbill. A superbill is a detailed receipt listing the diagnosis codes, the procedure codes, and the amount charged, in the format your plan needs to process an out-of-network claim.
You submit it to your plan yourself, and any reimbursement goes directly to you rather than to this office. Most plans accept these online in a few minutes.
If Medicare is your primary insurance, call the office before you schedule anything. The rules work differently from commercial insurance and we would rather explain that on the phone than have you discover it afterward.
What comes back depends entirely on your plan and on where you stand against your out-of-network deductible. Some patients are reimbursed a substantial share. Some are reimbursed nothing. We will not guess at your number, because a guess would be worth nothing to you.
Paying for surgery
For surgery this practice accepts cashier's check, personal check, wire transfer, and financing through CareCredit or Cherry.
For consultations and for non-surgical treatments such as injectables and laser procedures, credit and debit cards are also accepted. There is no additional charge for any payment method.
If you have no insurance, or your plan will not cover the procedure, CareCredit and Cherry both let you apply online in a few minutes and will tell you what you qualify for before you commit to anything. Our staff can point you to either.
What we cannot tell you
We will not predict what your plan will pay. Not because we are being evasive, but because the answer depends on your specific plan documents, your deductible status, and decisions your insurer makes case by case. A number given in advance that turns out to be wrong is worse than no number at all.
What we will do is tell you the full cost in writing before you commit to anything, give you every document you need to pursue reimbursement, and answer the phone when you have questions about it.
Questions
Often, when the condition affects function. Surgery undertaken purely to change appearance is generally not covered. Documentation of symptoms and functional impairment is what determines which category a case falls into.
This practice is out of network with every health plan. That does not prevent you from using your out-of-network benefits, and for reconstructive surgery our office bills your plan directly. If Medicare is your primary insurance, please call the office before scheduling.
An itemized receipt with the diagnosis and procedure codes your plan needs to process an out-of-network claim. You submit it, and any reimbursement comes to you.
Days to weeks. Start early rather than close to the date you hope to have surgery.
Yes. You receive a Good Faith Estimate with the full expected cost, listing every code that may be billed, before a date is held.
Not directly. Financing is available through CareCredit and Cherry.
It depends on whether they are symptomatic. Neurofibromas that are painful, bleeding, or repeatedly irritated are generally covered. Removal for appearance alone generally is not.
Next step
The first step costs nothing. Send photographs and a short history and Dr. Panossian will tell you whether surgery is worth pursuing at all. Cost is worth working out after that question is answered, not before.
Request a consultation