Hi, I got a letter saying my surgery won’t be covered:
"The requesting doctor has asked for the service mentioned above. This service is being denied by Cedars-Sinai Medical Group because it is not a covered benefit. This decision was based on your coverage evidence.
*Reason #1* services are excluded under Anthem Blue Cross. Check your member materials for guidelines and talk to your doctor about options.
You can get a free copy of the actual benefit provision or guideline that led to this denial by calling Cedars-Sinai Medical Group at 1 (800) 700-6424. Your provider can give you detailed information about your diagnosis or treatment, including the codes and their meanings.
The requesting doctor has been informed of this denial and can discuss it with Cedars-Sinai Medical Group’s physician reviewer."
Since reason #1 is not covered, I think the surgeon only contacted the insurance based on that reason. Can I reach out to the surgeon and ask them to try again, this time using reason #2? I don’t understand why the second reason wouldn’t be part of my plan.
The way the letter reads suggests that this surgery isn’t covered at all. Have you checked your Summary of Benefits to see if this is a covered procedure?
Your post is a bit unclear so I can’t give more specific advice.
Luca said: @Peyton
No, they clarify afterward that reason #1 is not included in the plan.
You could ask your provider to submit a new request with reason #2 as the main reason, but the insurance is aware of reason #1 too, and they might still not cover the surgery.
You may also need to appeal this decision. Without more details, it’s hard to offer better advice.
To me, it seems like surgery isn’t covered at all. I understand that pre-authorization can be denied for one reason and not another, so good luck!
@Peyton
I added the exact wording from the letter. I’d rather ask again than appeal since appeals can take over a month and my surgery is coming up soon.
Reason #1 is the issue here. For instance, if my doctor says I need weight loss surgery to address my pre-diabetic state, sleep apnea, and arthritis in my knees, but my insurance doesn’t cover it, that’s just how it is; they won’t change their mind on a non-covered procedure, no matter the reason.
From what you posted, it seems your surgery was denied because your plan doesn’t cover it. Whatever your doctor suggests isn’t a covered benefit under your plan.
The second reason may not matter if the surgery is excluded from your plan altogether.
I recommend reaching out to your insurance carrier to clarify your benefits and what’s covered for your surgery. You can also appeal the decision.
@Luca
I don’t see anything in the wording indicating that the procedure is denied due to the diagnosis rather than the procedure itself. You should call the medical group number to get the exact details for coverage because that will guide your situation.
If the procedure you’re talking about is primarily for infertility and not for chronic pain, it won’t matter if you submit diagnosis #2. They will likely want you to go through the diagnosis for the actual cause of the pain, if that hasn’t been done yet, and then receive treatment for that condition.
Luca said: @Oli
The pain is due to the fact that it needs to be removed. The diagnostic states this as well.
Your issue likely arises from the fact that your plan doesn’t cover infertility treatments, which is why they’re denying the surgery. Fertility problems seem to be the primary reason for the surgery, and your plan doesn’t seem to include that. You’ll need to work with your doctor to resubmit for approval. You can’t move to reason #2 without addressing the main reason for the surgery, which isn’t covered.
Luca said: @Oli
The pain is due to the fact that it needs to be removed. The diagnostic states this as well.
If removal is the first line treatment for the cause of your pain, you should be able to resubmit using diagnosis/reason #2 and get it approved. For example, my sister-in-law’s insurance denies an ultrasound if the diagnosis code is infertility, but an ultrasound is approved for many other medical reasons.
It’s hard to say what will happen without knowing your specific situation, but if this is a standard treatment for the condition causing your pain, switching to your second reason should help with approval. If your plan doesn’t cover the procedure at all, there might be another treatment option, which is why it isn’t covered. You really need to call them to find out.
@Luca
I’m going to guess this is about endometrial ablation or excision?
I’d recommend leaving out the kids’ aspect. Submit based on the pain and the need to treat the endometriosis; the improvement in fertility is just a side benefit you’re not focusing on.
“There is no covered benefit” suggests that the provider is not denying the surgery because it’s not covered, but that insurance is the one denying it.