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.
Thanks,
Vicki