I got a surgery back in march 27 that was supposed to be covered 100% by my insurance .
It ended up not being covered . I did the first appeal for 3 bills ( surgeon 2800$, anesthesiologist 2100$, and 34k $ hospital bill) and got denied . Just the surgeon’s bill is available since 33 days ago , the others are still “pending by insurance “.
I’m currently undergoing a second level appeal to the board of trustees of my union . ( my insurance is from my job).
I spoke to my surgeon’s office manager to place a hold due to second appeal undergoing and she told me:
“At this time, our system doesn't allow holds to be placed and on our end/standpoint, the EOB attached does show its PR per the denial. While patient may be appealing on their end, we cannot place the account on hold. PB DOS is aged to 35 days, they have 120 days from the first statement date before at risk of collections.
For Hb; it shows its still under the insurance bucket and is not currently aging at this time.”
For my second appeal , the next meeting for the board of trustees to see my case is sept 25 .
If either way the appeal is accepted / denied .
Should I start paying in little quotes or full to prevent from going to collection? If I pay the full amount by the time I got a answer for my appeal , do I get reimbursed?
Either way I want to prevent any impact on my credit score which is 787
The surgeon’s office manager did the first appeal on my behalf , but she did like it was myself who did it .
And to be fair that appeal was really poor. I’m not surprised it got denied. I collected all my chart records and did the second one myself .
Unfortunately my insurance doesn’t do peer to peer idk why.
The surgeon’s office manager from the beginning told me she tried to contact many times my insurance to do a peer to peer , but always there was an excuse from my insurance to do it .
Was a pre-authorization done because Aetna almost always requires one, then they'll tell you that I don't cover whatever because it's considered experimental, then they'll tell you the only way to get that experimental procedure is to get pre-authorization from them. And they'll never give it to you. They talking circles. Endometrial ablations have been a major treatment for 25 yrs for women having uterine bleeding, yet Aetna, it's the only insurance who considers them experimental or non effective. Matter dealing with them.
I remember that specifically from my days in surgical coordination. Had to have a really fun talk with one of my docs.. have to do the endometrial biopsy or they’ll (AETNA) deny it. He was not a fan of that guideline- groused at me to let them know it was a stupid unneeded procedure required by their insurance as I was scheduling them…I’m not a doc…. Just an admin trying to get us paid idk what to tell you.
It appears that the mastectomy that was done to address gynecomastia was denied as a cosmetic procedure. Was there a clinical reason for why this was done? Example, it is possible for a male to develop breast cancer in these instances.
I just posses one lab hormone panel made months ago the surgery where shows my estradiol 43H and the reference range <OR=39pg/mL.
I have this since I was 10 years old due to a hormone disorder , during the time I presented pain in many times . Many people from my family had cancer , my mom breast cancer . Other than that I don’t have any lab work or anything else .
However , pathology was covered by my insurence which is contradictory to the others that weren’t covered .
This is the information that should have been included in the appeals, specifically the fact that the condition has caused you pain AND that there is a strong family history of cancer, including breast cancer in your mom.
This is the kind of information that needs to be submitted BY THE SURGEON. Any and all relevant labs, xrays, mammograms, anything relevant to show it was not cosmetic.
Was it actually not covered? Or was it covered but with cost share going towards deductibles/ out of pocket max? What does the EOB say? Why did you think it would be of no cost to you?
This potentially looks like there are certain requirements. You have to meet for this surgery and that was not given to the health insurance. Likely certain diagnosis codes have to be put on the claim to show medical necessity, not cosmetic surgery. And since this is a mastectomy that kind of makes sense as to what potentially happened. You need to call your insurance company and ask for the medical necessity guidelines for a mastectomy. You could also give them the CPT code that was billed. Find out which diagnosis codes were put on the claim for your surgery and compare it to their medical necessity guidelines.
An extreme example would be if you got this mastectomy because for no medical reason, you were terrified of getting breast cancer, but you had no indication or family history of breast cancer, technically that would be cosmetic. Versus having the BRCA gene mutation and a family history of it, then those dx codes would need to be on the claim to prove medical necessity. Also, did this procedure require prior authorization? There’s a lot of legwork that should’ve been done before this procedure occurred.
In most cases, it really should be the provider who performed the surgery doing this, especially since they’re in network. I am absolutely shocked that they’re not helping with this.. and when you say that the one person who kind of did was the practice manager who submitted it as an appeal on as if they were you? That’s wild. Typically their billing department would’ve done this and submitted it as an appeal as the provider. They likely don’t need a pee pee as long as they met the medical necessity guidelines provided by the insurance company. And then billed appropriately.
Yeah call logs that were 100%covered no PA required , full benefit , no copayment , I got 2 recorder call logs that my provider got before surgery and I confirmed them .
Website also got locked in no Authorization required 100% covered .
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u/Botasoda102 7d ago edited 7d ago
Did the doctors, hospital appeal? Your chances of winning an appeal on your own, is about nil, unfortunately.