Denied Appeal and Plan Coverage

Hi, new to this subreddit… I’ve searched but can’t quite find an existing post that captures my situation, so I’m posting for suggestions/advice.

My husband decided to look into bariatric surgery last September (’22) and we figured we’d better call the insurance company to double check whether we’d have coverage to even start the process. We have Anthem BCBC PPO.

Now, I knew that my plan didn’t include bariatric services, however, we figured it wouldn’t hurt to ask if there were situations in which it would be covered. We spoke to a rep that told us if a primary physician deemed it medically necessary and we met all criteria on Anthem’s provided clinical guidelines and completed the necessary testing, the procedure would be covered.

With this good news, the process begun. After many tests and hundreds of dollars spent, the surgical center calls us last month to inform us that Anthem denied the surgery when contacted for pre-auth.

I filed an appeal with Anthem at the advice of my HR department, explaining all of the above, and just received a letter of denial today. They simply stated that the services aren’t covered under our plan, the end. Do I have any leg to stand on? I can file a secondary appeal, or, an external appeal, but is it even worth it?

Feeling pretty irritated that a rep led us to believe our circumstances would grant us coverage to find out there was a major miscommunication. Not to mention the hundreds I’m shelling out for useless testing…

TIA