Anthem denied continuation of care. Now there’s a peer-to-peer review.

I have anthem bronze HSA insurance through the marketplace (coverage started Jan 1 2023). The last two years I had CareSource (also through the marketplace) but switched at the beginning of open enrollment last year. I went to the hospital in Dec 2022 for what turned out to be gallstones. While a surgery wasn’t immediately necessary, I had a follow up that month and we determined removing the gallbladder was the best choice.

Finally got the surgery scheduled for Feb 2 and a couple weeks ahead of time I called Anthem to make sure it’d be covered and to see if I needed to submit anything first. I was especially unsure since I had just switched insurance companies. They said it would be covered and preauthorization wasn’t necessary.

Wednesday Feb 1, the hospital calls me to let me know that anthem had twice denied my procedure because the hospital is out of network for my specific plan. The hospital submitted a continuation of care request and the denial for that came less than 24 hours before my surgery was supposed to happen.

I tried to call anthem to get things sorted out but I was told by the utilization management rep that the doctor would have to do a peer-to-peer review of my case during which they will decide if my procedure will be covered.

The hospital is a major hospital in my city and is covered through many other employer-based anthem plans. Additionally, many of the surgeons are billed through one of the other hospital networks.

Meanwhile, I’m continuing to have gallbladder attacks waiting for this to get sorted out.

Has anyone had an experience like this or know the likelihood that they’d still deny it after the peer to peer review?

If they deny it so I have any room to fight that decision? I do not want to have to go through a bunch of extra appointments and then still wait months to get this surgery.

It seems ridiculous that the “network” can vary so much for the same health insurance company.