Physician filed incorrect CPT for pre-approval, I didn’t notice, now Anthem has denied coverage after the fact.

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
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