Insurance policy entitles me to coverage for elective in-network sterilization services, but they denied coverage for everything relating to my elective sterilization (bilateral salpingectomy) & cystectomy performed during the same surgery despite surgeon & facility being in-network. (OH, USA)
I underwent a elective bisalp for sterilization a couple months ago and despite preparing for everything, my insurance company is fully denying coverage of my bisalp & the ovarian cystectomy performed while I was under despite having been given cost estimates by my hospital based on my specific insurance policy and my policy entitling me to in-network sterilization coverage. My doctor and the facility that the surgery was performed at were not only in-network, but both had been previously covered by my insurance for past inpatient and outpatient services, including bright before my surgery.
Per my specific insurance policy on the company’s website, I’m entitled to coverage for elective sterilization procedures performed by in-network providers at in-network facilities and the costs of this procedure takes me to well above my deductible, so my insurance should not only cover it, but cover 80% of it since co-insurance kicks in after my individual deductible is met. Also, regardless of me meeting my individual deductible and my husband and I meeting our family deductible, my bill is much higher than my out-of-pocket maximum for both in- and out-of-network services.
Now my insurance company says I owe over $15,000 since they are not covering anything associated with my surgery, so I want to know how I should proceed and fight for the coverage that I am entitled to. I have heard that some people experience this if the insurance company doesn’t have a specific procedure code for billing (like a bisalp might need to be coded as a tubal ligation via bisalp instead) and my doctor is fully ready to adjust codes to the appropriate ones so my insurance will recognize them, but I’m at a loss as to how to best talk to my insurance company and avoid saying anything that would jeopardize getting coverage. I tried to reach out to an org that r/childfree recommends for legal advice regarding sterilization/birth control coverage, but they aren’t super responsive due to them being swamped.
Can anyone help explain my options moving forward and how to protect myself in this process? I’m in OH and have a plan through Anthem BC/BS.
