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What to Do if Insurance Denies Surgery

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Insurance companies are worried first and foremost about their bottom line. They will look for any reason to save money, even if that means denying coverage for medical procedures approved and recommended by your doctor. What can you do if your insurance company denies coverage for a surgery recommended by your doctor? Continue reading for a discussion of how to handle an insurer’s denial of coverage for surgery, and contact a seasoned and effective Los Angeles insurance denial lawyer if your insurance provider wrongfully denies you coverage for medical care.

What is a health insurance denial?

A health insurance denial occurs any time the insurance company refuses to pay for a diagnostic test, surgery, prescription, therapy, or any medical service or treatment. Typically, the denial comes after you have already received the service and paid your share of the cost, such as any applicable deductible or co-pay. The health care provider then bills the insurance company for the remainder, but if the claim comes back denied, the provider will turn around and bill you for the entire amount of the service, which can be hundreds or thousands of dollars.

When it comes to surgery, a health insurance denial often occurs before the surgery is ever performed. Often when surgery is recommended, the insurance company requires pre-authorization. This process requires submitting the request in advance to the insurance company for pre-approval. If the request comes back rejected, patients have to make a decision regarding their options. If the surgery can wait, the policyholder can proceed to fight the denial and go through the proper channels to get the surgery approved. When delaying surgery is not advisable, however, some patients choose to go ahead with the surgery, even if it means going into debt to pay for the surgery out of their own pocket. These patients can continue to fight the denial and seek reimbursement of their expenses if the surgery is eventually approved.

Either way, fighting the denial is extremely important to be able to afford costly surgeries, which is one of the main reasons people buy health insurance in the first place.

Reasons surgical coverage may be denied

Insurers may deny coverage for a medical procedure if they consider it either experimental or medically unnecessary. Insurers may also claim that a procedure is purely “cosmetic.” For example, insurance companies have recently been denying surgical treatments for lipedema because the treatments, such as liposuction, are also used for cosmetic reasons. Just because something is a cosmetic procedure in one context does not mean that it is not medically necessary in other circumstances; in the case of lipedema, such procedures are necessary to prevent or cure a debilitating condition.

California law, moreover, requires that insurers cover even procedures that are cosmetic so long as they are necessary to restore a patient’s appearance. For example, insurance providers must cover reconstructive surgery if someone’s face or other body part was severely damaged in an accident. Your California bad faith insurance denial lawyer will help you evaluate the reasons for the insurance provider’s denial and determine whether they are valid or if they can be successfully challenged.

When is surgery “medically necessary”?

Medicare plans follow standards and rules set out in state and federal law regarding when surgery might be medically necessary, but private insurers simply make up their own definitions and decide on a case-by-case basis whether surgery is medically necessary. But if surgery is doctor-recommended and accepted in the medical community to treat the condition, it should pass the test of medical necessity. The availability of a cheaper alternative does not make the surgery medically unnecessary. “Medical necessity” should be a medical term and medical decision; it should not have a cost component attached to it.

Many insurance carriers contract with medical groups and require decisions about surgery to go through the medical group. This way, the insurance company can claim some legitimacy for its decision to deny a claim and say that the insurer was removed from the decision making process. But inserting another layer into the process doesn’t negate the fact that the patient’s doctor already determined the surgery was medically necessary. Having that decision overturned by a separate entity that benefits financially from its relationship with the insurance company only serves to yet again inject considerations into the process that don’t have anything to do with the treating physician’s decision that surgery is medically necessary.

Initial steps after a denial

Insurance companies deny procedures that they believe are more expensive or invasive than safer, cheaper, or more effective alternatives. It is possible that your insurer simply does not know about the procedure or that some other error has been committed, rather than a bad faith denial.

If your claim was denied, it is worth making a few calls–to your doctor and your insurance company. It is possible that your claim was simply coded incorrectly. If you clarify the condition, the indication, and the treatment, the insurer may fix the mistake. The insurer might just need some additional evidence before accepting your claim, which you or your doctor can provide. Before you call, you should, of course, make sure that the treatment is not explicitly excluded by your policy (for example, controversial drug treatments). Your insurance denial lawyer can help you analyze your policy to establish what procedures are covered.

Options after a firm denial

If the initial steps to get coverage fail, you have a few options. You can speak with your doctor and your insurance company about possible alternative treatments. However, unless you want to forego the procedure, your course of action will likely involve challenging the denial. You can pursue an appeal with the help of an insurance bad faith denial attorney. You will first appeal the denial internally within the health insurance provider, and if they continue to deny your claim, you can pursue an external appeal.

Your California insurance lawyer can help you through the appeals process. It is important to contact an insurance denial lawyer as soon as possible after a denial. There are specific deadlines for filing an appeal, and they change depending on the circumstances. For instance, the deadline for filing (and the timeline for receiving an answer) is different depending on if you are awaiting the treatment, if you have already had the treatment and are seeking retroactive coverage, or if the treatment is required for an emergency.

Help is Available if Your California Health Insurance Claim is Denied

If you’ve had a claim for benefits rejected by your California health insurance provider, get dedicated and effective help appealing your denial by contacting the Los Angeles insurance claim denial lawyers at Gianelli & Morris for a free consultation at 213-489-1600.

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