Appealing Functional Endoscopic Sinus Surgery (FESS) being deemed "Not Medically Necessary"

I had a Balloon Sinuplasty preformed on me after my doctor stuck a camera up my nose and determined I had a deviated septum. After the procedure I found out that my insurance company, Anthem Blue Cross and Blue Shield, denied my claim and sent me a bill for $2000. I tried appealing the claim and was denied. They told me that I have to meet the conditions for CG-SURG-24. (here is a link to them: https://www.anthem.com/dam/medpolicies/abcbs/active/guidelines/gl_pw_a051164.html).

I figure my best bet is to prove option G. Which has 3 parts.

The first part is: Four or more documented episodes of acute rhinosinusitis (for example, less than 4 weeks duration) in one year; or
Chronic sinusitis (for example, greater than 12 weeks duration) that interferes with lifestyle; I went to the doctor a lot but I certainly don't have 4 documented visits in one year. Can I prove the second one or do I need documented evidence for that as well? the second one is easier but I never did "Trial of inhaled steroids;" because my doctor said to do the surgery instead. Is that a deal breaker? (How was I supposed to no this info beforehand….) The third criteria is: "Abnormal findings from diagnostic work-up, as indicated by any one of the following" Like I said, doc stuck a camera up my nose. So I definitively meet the criteria for this one, but I don't have any pics or videos from when he did that. Do I need some evidence of it?

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I figure I will try to prove all of these and send a letter back to them. But am I missing some other way to go about this? Like most people I have no idea how to go about insurance appeals.

submitted by /u/coolDude69420blaze
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