Denying a part of a surgical procedure that already happened.

So I had surgery with my employers state covered plan.

I talked to a surgical coordinator that spoke to my insurer a month prior. I have a name and date that said “no authorization needed.”

Have the surgery and one part of the claim is denied. It states in the claim that “we requested more information but could not get it.”

Now I got a denial letter saying that the procedure was experimental and not beneficial.

On the denial letter I see this: “Member billing by participating (in-network) providers (doctor or facility): If your care by a participating provider is denied based on medical necessity, the provider is not allowed to bill you for the denied services unless you knew in advance that the services would not be covered and you agreed in writing to pay for them.”

I reached out to the hospital stating this and they are conducting an “integrity review.” I contacted the office and plan for appeal, but based on that language I’m not even compelled to do that.

What next steps should I take?

submitted by /u/nightopian
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