[Anthem BCBS] Appeals kept getting rejected for an overseas emergency surgery
Hi all,
I had a skiing accident in Idaho in Jan 2023 and had to fly to my home country (18 hrs away by flight) 5 days after the accident for my passport renewal and visa stamping. I wanted to get an MRI in California (where I live and work) to decide whether I should risk flying but the imaging center had to wait for Anthem’s approval to get me an appointment. By the time they called me back I was already in my home country. I got an MRI right away and turns out I completely tore my ACL and MCL, and partially tore my PCL. My doctor recommended that I get surgery right away (because the best time is between 2-4 weeks after the accident), so I went into surgery the next day after consulting with Included Health (insurance concierge for the company I work at). Included Health said if the surgery is an emergency, it will be covered by Anthem through my company’s insurance benefit. It cost me around $20k out of my own pocket. I made sure I had all the bills in English and all the expenses are itemized.
When I finally got my passport back, I flew back to the US and filed for reimbursement from Anthem, with the help of Included Health. I have all the documents, including the bills + CPT codes, emergency letter, MRI scans, etc. Anthem denied the claim and I filed for appeal twice + a grievance. They kept rejecting the appeal with different reasons every time (CPT code missing, not emergency) through snail mail, each time after more than 30 days. But ultimately they rejected my grievance saying it was not an emergency. I have 12 months from the first claim submission to appeal, so I’m left with 4 more months.
I’m at my wits’ end and this has been an endless emotional, physical, and financial disaster. Does anyone have any similar case or have any recommendations? Any info will be much appreciated.