FrankTalk.org

I posted this in my other post about implant failure but thought I'd get better responses as a new post.

Before my original surgery I called my insurance to see if they needed prior approval and to see if it was covered. I gave them my plan number/info and they looked everything up. I gave them the CPT codes and let them know it was for a IPP surgery. They looked everything up and told me yes everything is covered including the device. Great good to go I'm thinking.

My device fails and I'm about to have surgery to replace it in about a week. Today 6-13-23 in the mail I get an explanation of benefits letter saying they are denying all charges for the surgery to the tune of $87,000 plus. Denied because they say it's in my exclusions ( which is funny because I expressly called them to confirm my coverage before the surgery not once but twice.) Obviously I don't have that kind of money and now I'm afraid that when I get to the hospital next week that they will deny me the surgery unless or until I pay off that bill. That would mean I will be totally impotent and unable to do anything which will be very devasting to say the least.

I know I have to call the insurance tomorrow and chew butt all the way to the top, especially since they told me it was covered, but I need ideas, information from anyone that can possibly help reverse this decision by the idiots at the insurance.

That sounds like an absolute nightmare, I’m sorry to hear that. What is your insurance?

JohnHC, i had a similar experience with BCBS Tx. My original phone call with BCBS I was told it was covered so i asked if they could send me confirmation in writing, well couple of days later I received a letter indicating coverage denied because of exclusion. My doctor fought it but could not get it overturned. Others on this board have said they were able to get theirs approved after initially being denied perhaps they will chime in on how they did it.

Another alternative is to shop around with the doctors as a self-pay cash patient, this past year the ranges in prices is around $25-35K including the implant, doctor fees and facilities charges. On top of that there's also the trip charges for hotels, meals and airline if you traveling to the doctor. Wish you the best.

I was in same boat. Each time I called someone had a different answer. I have cigna and they are terrible and plan is excluded they day. I wad a week out from surgery. This coming new enrollment at work I'm switching to bcbc of new jersey.