insurance

Families in the United States will find that SDR is often covered by insurance. However, sometimes it’s not that simple. Coverage depends on many factors, including the type of insurance you have (and your specific plan), the state in which you live, and the surgeon you choose. Sometimes they pay completely (minus your deductible), sometimes they pay a percentage (e.g., 80 percent, 50 percent), and sometimes they refuse to pay anything.

When I pursued SDR, my insurance was a Blue Cross Blue Shield (BCBS) PPO plan. PPO plans offer more flexibility to see a doctor outside of the plan’s network, although they may reimburse less for an out-of-network provider.

HMO plans don’t allow you to go to an out-of-network doctor, so some people with an HMO can run into trouble if their SDR surgeon is considered out of network. However, you may be surprised to learn who is considered to be in network! St. Louis Children’s Hospital was considered to be in network with my plan, even though I lived a thousand miles away. As a result, my St. Louis SDR and PERCS were completely covered, minus a small deductible. This is common.

Families who wish to pursue out-of-state SDR sometimes have difficulty getting coverage when another surgeon performs SDR within their state.

Sometimes, a doctor can write a letter to the insurance company to try to convince them to pay, so this is worth looking into as well. 

You can call your insurance company to check your coverage with your chosen surgeon. (And if they agree to provide coverage, be sure to get that in writing.) You’ll need to give them two codes. If you’re pursuing SDR for cerebral palsy, the first code you’ll need is the diagnosis code (IC-D10), which is G80.9. The second code is the procedure code (CPT), which is 63190. If you’re considering SDR in St. Louis, their office can also help you check your insurance coverage and navigate your options.