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Author Topic: How to appeal insurance company's decision  (Read 958 times)

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Offline Daisy2512

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How to appeal insurance company's decision
« on: December 27, 2005, 01:05:12 AM »
Hi again.  I was a member of this website for several months as "pipervlh", but then thought I wouldn't be coming back to Kneeguru and cancelled my membership.  So here I am again, as Daisy2512, looking for help! 

I had OATS surgery at the end of September and am doing well with that.  But the insurance co. has denied my claim because it is "experimental".  Now, I read all their reference research and can understand their hesitancy to pay this claim....HOWEVER....

-My doctor's office got pre-approval for this surgery (OATS, less than 1cm in size)

-I confirmed with the insurance co. prior to surgery that we had pre-approval and if there was anything I could do to avoid having problems.  I was told that it would be "OK as long as the Dr. stays within the parameters of the approval".

-The company's handbook authorizes OATS only when it is in a local area, less than 1cm. The company's policy bulletin also has the same statement.

-They now say that they have no record of giving a pre-approval/pre-certification.

I've read on several websites that denials are the standard procedure these days and only if the patient files an appeal, will they actually read the claim/surgical notes.  I'll fight this decision with everything I've got, and I think I'll win.  But I'm wondering if anyone here has had a similar problem?  Any suggestions? 
Did your Dr's office help with the appeal or did you have to do it yourself?
If the Dr's office sends me the entire bill, do I have to pay it?

Insurance co:  Aetna
State: Virginia

Any info would be appreciated.....GREATLY appreciated.
« Last Edit: December 27, 2005, 01:09:05 AM by Daisy2512 »

Offline misshilde

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Re: How to appeal insurance company's decision
« Reply #1 on: December 27, 2005, 06:13:04 PM »
lovely, burocrats...your doc's office will probably help you as it is more likely he/she will get paid by insurance than you..if insurance gave ok, your doc will have records of that...have never had any problem so far my self , but my son had some issues with dental insurance when he broke both front teeth..and doc was happy to keep at it ..after all you have paid their premiums.. it also comes down to what can happen in...will you later be a candidate for TKR...that's very expensive and not a new thing and they have to pay for that...good luck

born with bad knee
83 patella ligament pierced by iceicle
84 50%  hamstring rip
86 lateral meniscus tear
more dance 
99 menisectomy(finally)
more dance
patellar & quad tendontis
05 LR, bonespur removal, general clean out, stage 4 OA
oct 06 illiophoas release( hip ok) but knee still bad...

Offline Daisy2512

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Re: How to appeal insurance company's decision
« Reply #2 on: December 27, 2005, 11:27:23 PM »
Thanks, Hilde.  I've spent most of the day coming to the same conclusion.  My Dr.'s office said that they will continue to submit paperwork until they exhaust all options.  Then, if that happens, they will send me a bill and I'll fight the insurance company too.  It just boggles my mind!!!!  I also agree with your thought about what the other scenario would have been (i.e. TKR).  But I don't suppose they consider this to be cost-saving at the moment.

Oh, and I found out that my office has someone who can call the insurance company and find out what the heck is going on.  I'm waiting until I have more "proof" that the insurance co. is not doing the right thing, but it is nice to know that I have another avenue!!!

Thanks, again, for the reply.

Offline brattkids

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Re: How to appeal insurance company's decision
« Reply #3 on: December 28, 2005, 02:55:26 AM »
I am also fighting my insurance company with the same issues. I gained pre-approval and now I get a notice that they deem the proceedure experimental.

The thing I dont understand with me is that I have had other OATS proceedures that they did pay for and now they are considering it experimental and after I gained pre-approval!! Hope your fight goes well!!! Keep me posted on how you do

4/04 microfracture
5/04 debris removal
8/04 OATS with synthetic plugs
11/04 OATS traditional autograft medial femoral chondyle
05/05 debris removal and OATS assessment
6/05 Cadaver Allograft OATS lateral femoral chondyle
9/05 OATS redone could not save allograft plug
12/2006 2007 and 2008 scop