Got another surprise bill today for lab work for GERD that I thought my BCBS PPO would cover. It got denied. I called BCBS but they just kept saying it’s not covered under my policy. I asked what policy they meant, but the agent couldn’t explain. All I have is the benefits packet from my employer, which is vague. I can’t find any actual policy document on the BCBS portal either. Is this all just random or does anyone know how to find out what’s really covered?
Why was the doctor running vitamin D tests? The provider can appeal if they think it was medically necessary.
Blaine said:
Why was the doctor running vitamin D tests? The provider can appeal if they think it was medically necessary.
I’m not sure. I assume it was needed, but that’s why I see a doctor in the first place. This wasn’t super expensive, but how do I know if the doctor’s recommendation will be covered? Should I be asking for prior authorization for everything just to avoid surprises?
@Oaklan
You don’t need prior authorization for everything, but most doctors explain why they’re doing a test. You can ask them directly if you’re unsure.
They should have sent you an EOB explaining why it was denied. If you didn’t get one, call and ask for it to be emailed.
Nico said:
They should have sent you an EOB explaining why it was denied. If you didn’t get one, call and ask for it to be emailed.
I got the EOB but all it says is 82306-LAB-PATHOLOGY (1) and a line saying the charge isn’t covered. Is that normal?
@Oaklan
I used to work for Anthem, and vitamin D screenings usually aren’t covered unless there’s a specific reason. GERD isn’t one of those reasons, so if that’s the diagnosis, that could explain the denial.
@Lyle
That makes sense. What bothers me is that I don’t know who made the mistake – me, the doctor, or the insurance. I wish there was a way to check before getting the service. It feels like I’m just stuck in the middle with no control.
@Lyle
That’s probably exactly what happened.
You can request a benefits booklet from BCBS or download it from the portal. It explains what’s covered. For really specific stuff like billing codes, those are in long policy documents, usually found in the provider section of their site.
@Bell
Yeah, those policies are often too technical. But sometimes they explain stuff like why a leg amputation can happen only once even though we have two legs.
@Bell
That’s helpful, thanks. Boring is fine – if I have to fight them, I’d rather have all the details.
Screenings like that get denied if the doctor doesn’t clearly tie the service to the diagnosis. For me, vitamin D tests are covered because I have type 2 diabetes. You could ask the insurer for the list of diagnoses that qualify.
You should have a document called the Summary Plan Document (SPD). It’s either in your employer portal or the insurance portal. It explains coverage and amendments. For denials, CARC 96 usually means:
- The procedure wasn’t pre-approved
- The billing code was wrong
- The provider isn’t in-network
- The plan doesn’t cover the service
- Coverage lapsed at the time of service
Check the diagnosis code the lab billed. Sometimes they use a generic code instead of what the doctor wrote, and that causes denials.
This is the kind of policy you’re probably looking for: Anthem Medical Policies. They should have been able to show you something like this.
There’s no single policy that explains everything. Coverage depends on your employer, state laws, and medical policies. But your denial should have more info than just ‘not covered.’
Insurance companies deny, delay, and defend claims. It’s common.