Appeal Letter Help

My mom was denied in-network coverage cost for an out-of-network provider.

Background: -They called her on Friday night at 4:30pm to tell her she been denied. -Her breast cancer surgery (covered) with breast reconstruction (denied for in-network) was scheduled and performed on Monday morning. -Her insurance is also backing out of commercial insurance very soon and going Medicare Advantage only.

Based on her due diligence, there were zero plastic surgeons with the same hospital privileges as the breast cancer surgeon. There were no in-network doctors.

The insurance company claims there are. After researching each doctor from their portal, one had their practice closed in 2021 and the remainder had no hospital privileges at the same hospital as her surgery. They were listed as “plastic surgeons” but mostly ENT, Veins only, children craniofacial specialist, dermatology and other unrelated specialties to breast reconstruction.

Is there any arguement about the timeframe of the denial being essentially the night before surgery?

I’m trying to make the argument clear about the misrepresentation of the provider directory. You can’t pull up “plastic surgeon” and every doctor listed is expert in breast reconstruction post breast cancer removal.

I’m open to any opinions or experiences to help get a reversal on this decision.

Thanks in advance!

submitted by /u/pozattitude
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