Experimental Procedure but Wasn't Before?

yorkriver1

Guru
1000 Post Club
1,734
Virginia
Any suggestions for this situation?

Without having the coding or Summary of Benefits to review, I have been asked by a friend to assist a policyholder not in my book of business. This is a pre-authorization refusal. Naturally, I won't get directly involved unless the person can't get help from her existing agent, and not without an AOR.

The insured says the procedure involving a skin graft to help heal a surgical wound has been denied as experimental.

She says the same surgery was covered before (on the other foot) by the same carrier. Perhaps a coding error, maybe the plan has changed. The agent can help with a claims appeal if necessary.

I called the carrier, who I also represent. They suggested the agent can get the documentation of the refusal and they will review with claims dept. I told her to ask her agent to get involved, and gave additional possibilities.

If the above all fails:
1. ask the providers to help with low income sliding scale for the surgery
2. contact state "Managed Care Ombudsman" for assistance
3. seek other sources of help, such as Patient Advocate Foundation or other charities
 
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