Insurance Denied Your Surgery: How to Appeal

Appealing an Insurance Denial for Spine Surgery in Los Angeles, CA

Whether you’re having fusion surgery to stabilize your spine or a microdiscectomy to ease nerve pressure, there are many procedures that can provide much-appreciated relief from back, neck, or radiating nerve pain. However, the average cost of spine surgery can easily be $100,000 or more. Luckily for most patients, insurance covers the bulk of these expenses, but what happens if your insurance company denies your claim? While this can be an instant source of frustration and stress, there are things you can do to appeal a denied claim and restore your peace of mind.

Talk to Your Spine Surgeon

Odds are, your spine surgeon has had to communicate with insurance companies denying claims for patients before. Most Beverly Hills spine surgeons have office staff who are familiar with steps that can be taken to appeal a claim. Also, talk directly with your spine surgeon and explain the situation. The surgeon may be willing to call, email, or send a letter to your insurance company on your behalf.

Understand the Appeals Process

Each insurance company is required by law to have an appeals process in place. Find out the specific steps you need to take to file an appeal and follow their procedures to avoid delays in getting your appeal reviewed. According to HealthCare.gov, you have the right to file two types of appeals if your claim is denied.

  • Internal appeal – This is when the insurance company does an internal review of your claim denial to determine if they will reverse their decision.
  • External appeal – You also have the right to have an independent third party review your denied claim. In this case, it will be the third party that makes the final decision, not the insurance company.

 

Be Polite and Reasonable When Communicating with Your Insurance Company

While you may be understandably upset, a sour disposition will only make the situation more stressful for everyone involved. Realize your contact person at your insurance company likely had nothing to do with your denial. Be polite and explain your situation. Yelling and screaming will only create instant resistance and animosity.

Present as Much Evidence as Possible

Claims for spine surgery are often denied because the insurance company sees the procedure as elective, not necessary. While there are times when this is true, most patients are only likely to opt for surgery when nothing else is working or when quality of life is seriously affected. Humanize your situation as much as possible by gathering evidence to show why surgery wasn’t just optional in your case. Evidence may include:

  • A letter you write detailing your personal experience with pain and how it has affected your quality of life (both personally and professionally)
  • A letter or statement from your employer if you have a job that requires your spine to be as healthy as possible
  • Your complete medical history and test results related to your spine pain (your doctor’s office can help with this)
  • A detailed account of other treatments you attempted prior to deciding spine surgery was your best bet for relief

Prior to getting spine surgery, talk with your doctor or a spine specialist to determine if there are any non-surgical efforts to manage pain that you haven’t yet tried or considered. Some patients also report positive results with alternative treatments like acupuncture. If surgery is best for your situation, move forward with the procedure and keep the above tips in mind in the event your claim is denied.

When their claim has been denied for minimally invasive spine surgery, Beverly Hills residents have a variety of options. Get in touch with The Spine Institute to schedule an in-person evaluation and find out if there is another form of treatment that might alleviate your pain. Call 310-828-7757 today.