June 2022: scheduled a total laparoscopic hysterectomy for October 18, 2022. Note: it was always going to be a hysterectomy, nothing less
October 5: receive pre-approval letter from Anthem for the procedure. Filed it away.
October 18: surgery
January 17, 2023: receive denial letter Anthem, grounds that they pre-approved "laparascopic treatment of endometriosis" NOT "removal of womb". Note: the code they refuse to pay is for the HOSPITAL, not the surgeon. I am pissed because I wad always going to have the hysterectomy so feel Anthem is being shady.
I pull out the old pre-approval and yep, doctor's office screwed up. Anthem saw the mismatched codes so obviously denied. I only get one appeal so I am trying to get my ducks in a row.
What is my best approach?
Option 1- pull my old medical records and show the three criteria for approval have already been met (prior visual diagnosis of endo, prior surgical removal of endo, prior hormone-based treatment was ineffective) and appeal to Anthem directly, though it was the doctors office mistake for filing the wrong CPT for pre-approval?
Option 2 – let the hospital and doctors office duke it out themselves (this terrifies me, as I feel I would end up stuck with the bill)
Option 3- send my medical history over to the surgeon so they can retroactively file the correct pre-approvaL CPT, but have the documentation at hand to make it easier
Or something else?
TLDR: Surgeons office filed the wrong CPT for pre-approval so Anthem denied the actual claim. I get one appeal.
submitted by /u/SlothMaster223