Pre-Authorized Procedure Denied – Appeal?

Earlier this year, I had a diagnostic joint injection done for chronic SI joint pain. The procedure was pre-authorized by my insurance company (Anthem) and subsequently covered. I was told the next step would be a confirmatory diagnostic injection as it’s required by insurance before they can authorize a longer-term treatment. I once again received pre-authorization and had the procedure done only to find out the claim for the second injection was denied.

In the letter I received, I was told it was denied because they require three months between joint injections. However, when I went to the website they linked showing how their contracted agency (Carelon) made their decision, it states the three month interval is for therapeutic injections – not diagnostic injections.

According to my insurance company, diagnostic injections require anesthetic to be injected without a steroid. It seems that I had both anesthetic and a steroid injected despite it being labeled “diagnostic.” I had no control over the fact that a steroid was injected but I am assuming this is part of the problem/it was coded as such.

I am under the impression my provider is the best person to appeal on my behalf, but I am not even sure it’s worth it and will go anywhere? Any insight on the appeals process would be appreciated. Thanks.

submitted by /u/biologycellfies
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