Insurance denying diagnostic services without proving info on coverage
I have symptoms for an autoinflammatory genetic disease (confirmed by consumer genetic testing but that's not valid for diagnosis) and rheumatologist is ready to diagnose it and prescribe treatment because they believe my symptoms and blood tests match the condition but needs medical grade genetic testing and consulting to confirm. My health insurance is denying the testing preauth and consulting bills. Every rep is giving me different info on why and what my benefits cover (some claim never covered, some say covered only for fertility services, others say covered when medically necessary) and they are not providing a current plan summary or plan document that would show what is actually covered despite many requests on my end for that (they point to their website, which only contains an old one from a few years ago that is about plans that my employer offered in the past – they have changed the plans since then). Even the insurer's website, their app, and the old plan summary contain conflicting info on what is covered, nothing says what is excluded… I received a denial letter that says I can only meet medical necessity criteria if my syndrome was apparent before age 1 or if I'm an abnormal fetus, but my doctor said it refers to the wrong genetic panel and not the one she actually requested. Any advice on what my rights are in this situation, what I can request, anywhere I can file a complaint (if warranted), or whether there is any benefit to getting an attorney involved (I have legal insurance)? I can't even get a straight answer on what my coverage is. From what I can understand from medical literature and per my doctor, the testing and consulting is a required part of diagnosis, but costs are prohibitive. Doctor and lab are in both network and I've maxed out my out of pocket, so this is not part of the issue. Same insurer is also denying me for a vaccine that ACA/CDC say they should cover…
submitted by /u/medically-bankrupt
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