Anthem denying claim for surgery after already approving prior auth for the surgery
Hello, we have the above listed insurance. My husband is FTM and recently had top surgery. His surgeon sent over a prior auth for the surgery with procedure codes 19350 (nipple/areola reconstruction) and 19303 (mastectomy) and it was approved. We proceeded with the surgery and now insurance has denied the claim leaving us with a bill that is over $40,000 which we cannot afford. The reason they are denying the claim according to them is due to the diagnosis codes which are: F649 (gender identity disorder, unspecified) and F640 (transsexualism). They are saying our plan does not cover gender affirming care and even with the pre-approval for surgery that they surgeon should have called them to verify our benefits. My husband had talked to one of their representatives before the prior auth and she had informed him that our plan did cover those benefits and even sent him links to look up the requirements he would have to meet to qualify for coverage. We do not have an exact date on the phone call just a round about month that he called.
Our insurance plan was renewed on 7/01/2023. His surgery was 7/24/2023. While reviewing our medical plan looking at the previous years plan 2022-2023 under limitations and exclusions it does list "sexual transformation- surgical care or medical treatment or study related to the modification of sex (transsexualism) and related services, or the reversal thereof" as not being covered. BUT I reviewed the new plan for 2023-2024 which falls under when he had his surgery and sexual transformation has been completely removed from the limitation and exclusion list.
Do we have a chance of winning the appeal? What should we include in our appeals? Our plan only allows for two appeals. One internal and an external review.
submitted by /u/Lakin2011
[comments]
