Difficulty with Anthem reimbursement for transgender healthcare

Back in October of 2023 I got top and bottom MTF surgery with an out-of-network surgeon. I have a PPO plan with Anthem. Their guidelines say I was required to get prior approval, which I did. Insurance covered the majority of the hospital stay, anesthesia, etc., but the surgeon's costs were about $29k, which I paid for out of pocket. Once I was back home, I submitted all the paperwork, and of course they managed to find ways to drag the process out forever, but finally I got my reimbursement, which totaled $80. What they covered was $1,043 of the $7,150 top surgery, $963 of which I guess went to finishing off the out-of-network deductible. What they didn't cover was any part of the $21,000 bottom surgery. They straight up just say that their obligation is $0.

I'll admit to being kind of an idiot when it comes to the nuances of health insurance. But when it comes to a medically-necessary procedure that I got prior approval for, even with it being out-of-network, aren't they at least required to reimburse me a "maximum allowed amount?" I appealed the claim and got denied, so I'm starting to doubt my understanding of this stuff, but I can't figure how they can justify not covering it at all.

Thanks in advance for any advice/insight.

submitted by /u/Garfi2r
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