UHC / Oxford denying me for items that aren’t covered. What are my options of recourse?
Age: 31 Zip: 11739 Income: $67.5k
To preface, because I can't edit the title, I will say that they denied me for two items, and verbally told me the third was covered.
I'm looking to do neurofeedback (an FDA approved procedure).
It's a little funky because one of the CPT codes is medical and the other is mental health and the two departments don't seem to communicate with each other. The CPT codes are 90901, 95816, and 90876. They denied me on the first two in writing, but verbally told me that the third would be covered.
One of the codes, specifically the EEG-portion generally isn't covered by any insurance. However it's required for the rest of the treatment (which would be billed under 90876). They failed to provide me with a list of in-network providers; but again since it generally isn't covered, I suppose that's why.
I put in a gap extension for all 3 because there are not any providers near me that are in-network and convenient for me. The provider I want to see is out of network only and does not take any insurance. Of course, despite me telling them this, they want to make me play "insurance gymnastics" as I call it and try to make him negotiate a rate with him.
Furthermore (and I have no idea how they get away with this) I'm not offered a single plan with out of network benefits at my employer. Even the gold plan is in-network only.
I do have a referral from my neurologist (although I do not need referrals) stating why I need the procedure (ADHD, depression, and it's also useful in helping epilepsy) and also from my therapist.
Thoughts? Thanks
submitted by /u/churning_medic
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