UHC paid claims to surgery center but is denying Dr’s charge saying surgery was not medically necessary?

Hi fam! I have been back and forth with both UHC and Vanderbilt billing and have not been able to resolve this. I had an endometrial ablation and this was performed at an outpatient surgery center. I paid my coinsurance amount at the time of the procedure and was told repeatedly that since the procedure was approved by my insurance and I had met my out of pocket max for the year that there would be no additional charges.

7 Months later I get a bill from Vanderbilt from the Dr who did the procedure saying that UHC has denied the claim saying they did not think it was "Medically Necessary". This is after several years of diagnosed menometrorrhagia and several attempts at conservative treatment through various hormones and birth control. Everything I have found online states that based on this my procedure should have been considered medically necessary.

Through many many hours on the phone going back and forth between and having thruway calls with both I have been told first that this is double billing because the CPT 58563 should not have been charged on top of the original and paid CPT codes 58353 and 58120? But Vanderbilt insists that this CPT 58563 is a "professional" charge and is allowable to bill for. And because insurance has denied it due to "Medical Necessity" rather than double billing they are insisting I must pay.

At first UHC said it was because they had requested medical records from my Dr and they did not send them. I finally got them to escalate this to a team that ensures compliance from Drs with regards to medical records request and I had them review this and they again stated that they are upholding their decision to deny this due to Medical Necessity.

How is this even possible when they already approved more than $17k worth of claims paid to the surgery center for the exact same procedure?

I have sent through my own appeal with my documentation of my years long symptoms and unsuccessful treatment and now have to wait ANOTHER 45 days. I have been calling and taking detailed notes since the first bill came in May and since I cannot get anyone to do anything they are close to sending me to collections.

Are there any other steps I can take? I feel like I am reasonably intelligent and have spent so much time on this and I DO NOT UNDERSTAND.

submitted by /u/FrozenCustard4Brkfst
[comments]