$15,000 patient responsibility, claim denied – "not medically necessary"
I'm midway through trying to get my claim covered, but have been unsuccessful so far. I'll keep things brief… have been having sleep issues for years (undiagnosed) but got worse last year.
Seeing sleep psychologist (Dr. P) who sends me to a neurologist Went to neurologist (Dr. N) who recommended sleep study Dr. N's office calls my insurance and is told no pre-auth is needed Pre-pay hospital my estimated responsibility ($800) Schedule + complete sleep study (October '23) Dr. N is about to retire, and feels as though the sleep study is fairly normal Dr. P sends me to see a pulmonologist who specializes in sleep (Dr. Pul) Dr. Pul reviews sleep study, and determines that a new study is needed (plus another set of tests the following day > MSLT) Dr. Pul office requests pre-auth from insurance and is denied, "not medically necessary" Dr. Pul does peer to peer, and pre-auth is approved Pre-pay hospital my estimated responsibility ($1300) Schedule + complete sleep study/ MSLT (Feb '24) FINALLY get a notice from insurance that Oct sleep study was denied, and I was responsible for the $15,000 bill, "not medically necessary" Call insurance who says they did not get appropriate documentation/ records on why Oct sleep study was needed from Dr. N office Work with Dr. N's office to send records (Dr. N is mostly retired at this point) Insurance never receives records Work with Dr. N's office to resend records Insurance reviews records upholds their decision/ denial of coverage due to it being "not medically necessary"
What's my next step?
There's no way I can afford a $15k bill, and have already paid about $2,000 for these 2 procedures.
My sense is that Dr. N's office doesn't really care because it's not "their" bill (it's the sleep lab who hasn't been paid yet), and Dr. N is basically retired (so I think the peer to peer is off the table).
I'd like to appeal, but I'm wondering what I'll need to do that to get the denial overturned? Also, if the Feb sleep study/ MSLT WAS medically necessary, shouldn't the first one also be? Dr. Pul wouldn't have known to do the 2nd sleep study/ MSLT without the results from the first.
Help appreciated!!
submitted by /u/beekeepingandhoney1
[comments]
