Revision Surgery- Denials & Appeals

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Robyn727
Robyn727 Member Posts: 1
edited June 2014 in Employment, Insurance, and Other Financial Issues

Hello! I am new to the board, just looking for some advice on a recent insurance denial- or should I say 4 denials. I had a lot of issues after my chemo port was removed. It left a huge, painful scar. My plastic surgeon said it was placed in a bad spot by my general surgeon, and when my implants "settled"- it made the scar stretch and hurt. So he revised the scar to try and close it better... now insurance is denying it saying it is "cosmetic." Has anyone else had a similar issue? Or maybe just some advice on dealing with an external appeal? That's my next, and final, step. Thank you :-) 

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  • itsjustme10
    itsjustme10 Member Posts: 796
    edited November 2012

    Didn't your PS get a pre-approval for you?  I would turn it over to their billing department and let them file the appeal as being medically necessary - they do this all day long, and should be really experienced at it.

    When I had my BMX, I completely stopped reading any EOB's that were mailed to me, after I had more than $200,000 in denials - one of my friends told me to forget it, it almost seems like they automatically deny everything, and the doctors' offices would straighten it all out.  She was right.  I ignored it all, they dealt with insurance, and I later got a $20.00 bill in the mail, for one missing co-pay.  I paid it. 

    Good luck!! :)

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  • janiceg415
    janiceg415 Member Posts: 144
    edited November 2012

    Don't be so sure that the provider's billing office always finds a way to get it paid.  I had a uniMX with 1st step reconstruction on 2/23/12, stayed less than 24 hours.  They billed it as >6 hour recovery care, as I stayed over-nite in a surgical suite at the outpatient surgery center (not the hospital) and they are denying it for the 3rd time, even after my oncology surgeon wrote that she felt it was necessary.  Now the only option I have is to appeal it on my own, they have everything from the Provider and Clinic notes, etc. so what more am I going to be able to add that is going to confirm that it was medically necessary and not just for my or the Dr's convenience.   

    The charge is $2029.00 which I don't have.  ANYONE out there with an idea of what I can use to confirm that this this was in a)accordance with generally accepted standards of medical practice,  b)clinically appropriate for procedure. 

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  • Chickadee
    Chickadee Member Posts: 4,467
    edited November 2012

    There is always your states insurance commissioner. Insurance companies don't like to hear from them, or your senator or congressman.

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  • itsjustme10
    itsjustme10 Member Posts: 796
    edited November 2012

    Weren't you pre-approved for the 6 hour stay? If you were, it should be in the same letter as the surgical pre-certification that most companies require you get from them. 

    Have you sent them a copy of the pre-cert?

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