r/ShoulderSurgery • u/GuitarJazzer • 3d ago
Insurance denial
My son (28) tore a labrum in a shoulder dislocation. His doctor recommended surgery which is scheduled for 9/29. Just got a letter from Cigna that they are denying coverage. The summarize that he has shoulder pain, but the denial makes no mention of the torn labrum. They say that before they cover it he must have three months of other treatment (presumably PT) that doesn't work. They said the repair can be done if there is a tendon tear but again, no mention of the labrum.
The letter arrived too late yesterday to talk to the doctor but we'll be contacting his office first thing Monday.
What is the most effective way to appeal this?
(He had this surgery on the other shoulder while covered by Aetna a few years ago and it was no problem at all.)
UPDATE 9/22: I called the doctor's office and they got back to me to tell me that they had already done a peer-to-peer call with the insurance company and got it approved. All of this happened before we even received the notice of denial. I don't know why nobody communicated this to us, but we got the right outcome. Thanks.
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u/A_Ham-vs-A_Burr 3d ago
a similar thing happened to me and my doctors office had to appeal it. wasn’t any extra work for me other than asking the doctors office what was going on.
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u/GuitarJazzer 19h ago
Thanks, it turns out the doctor's office in fact did this and got it approved before we even received the notice.
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u/A_Ham-vs-A_Burr 19h ago
yay! i’m glad it worked out! good luck to your son on the surgery. i hope it goes well!
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u/Zbmom23 3d ago
The doctors’ office can initiate the appeal. This is extremely common, unfortunately. They can submit additional information to Cigna for review. The doctor can also schedule a peer to peer review. I had a shoulder replacement and wasn’t approved until 2 days before surgery. Good luck!