A New Jersey woman thought her neck surgery was approved. Instead, she ended up facing a bill of more than $100,000, two rejected appeals, and months of uncertainty. Her claim was eventually paid in full. Here is what went wrong, how it was fixed, and what you can do if it happens to you.
A surgery that couldn't wait
She needed an operation to repair a ruptured disc in her neck. She was in severe pain and partially paralyzed. Her family believed the procedure had been pre-approved by her health insurance company.
On the day of surgery, she was already prepped, in a gown and on an IV when the procedure was paused. The insurer had not authorized it. Given her condition, she went ahead with the operation anyway.
The denial
A week later, a letter arrived: the claim was denied. The insurer said the artificial spine device used in her surgery was not FDA-approved for her specific situation, and that coverage had not been approved in advance.
The total charges came to more than $126,000. That included about $37,000 for the spine device and nearly $9,000 for anesthesia. At one point, she was responsible for about $110,000.
Two appeals, two rejections
She filed two internal appeals with the insurer. Both were denied. After a local TV consumer team got involved, her doctor's letters of medical necessity were sent to the insurer. The answer was still no.
The step that worked: an external review
Once her internal appeals were used up, she could ask for an external review. That means an independent third party, not the insurance company, looks at the case and decides whether the claim should be paid.
The independent reviewer sided with her. The denial was overturned, and $126,680.25 in charges was covered.
In a statement, the insurance company said its decisions follow evidence-based practices and regulatory requirements. It said it had supported her right to an external appeal.
What to do if your claim is denied
- Get prior authorization in writing. Before a planned procedure, ask your insurer and your doctor's office to confirm approval, and note the reference number.
- Read the denial letter closely. It must explain the reason and how to appeal. The reason tells you what evidence you need.
- Ask your doctor for a letter of medical necessity. It should explain why the treatment was needed for your specific condition.
- File an internal appeal on time. Under the Affordable Care Act, you generally have 180 days from a denial to appeal.
- Request an external review if the appeal fails. An independent reviewer decides, and the insurer must follow the decision if it rules in your favor.
- Get help if you need it. Your state's insurance department can explain your rights and the external review process.
- Keep a paper trail. Save every letter, bill and call note, with dates and names.
The bottom line
A denial is not always the final answer. In this case, two "no" decisions from the insurer were reversed by an independent review. Knowing your appeal rights, and using all of them, can make a six-figure difference.
This article is based on a news report and is for general information only. It is not legal, medical or insurance advice. Appeal rules vary by plan type and state.