Undertaking surgery with no pre-authorisation
Hi!
I am an international student without a good understanding of the US healthcare system. I have a surgery scheduled to fix a deviated septum that has been causing me a lot of issues for the last 5 or 6 years now (I basically can't breathe through my nose and can't sleep or exercise properly or as a result). I have student insurance with Harvard Pilgrim. The university always tells us it is a premium insurance.
Anyway the surgeon's office calls me to say that they are unable to get a pre-authorisation for the surgery because the insurance provider doesn't require pre-authorisation for this procedure, and instead a claim should be filed after the procedure. They told me this was unusual and it's up to me how to proceed. I called my insurance company and they cannot tell me if I will be covered because there is an exclusion relating to septum surgery, that it is not covered except in the case of "injury or chronic sinusitis". I do have a diagnostic code of chronic sinusitis, but the insurance company rep still told me that they cannot be certain it will be approved because of the exclusion they will be extra rigorous, and depending on the way the billing codes are processed the most they can say is it is "possible to be considered".
So now I have to decide if I want a surgery (in 10 days!) where I risk being liable for 10s of thousands of dollars (this would completely ruin me financially), or I continue to suffer with my condition despite paying thousands of dollars a year for supposedly premium coverage.
Can anyone give advice on if this situation is normal? Would it be reasonable to go ahead with the surgery? How common is it to get denied for a claim for a procedure that at first glance it seems obvious I should be approved for (given my diagnostic code for chronic sinusitis). The healthcare provider is expecting me to make the decision but I feel totally not equipped to be able to assess the situation, and am extremely upset about the prospect of not getting treatment.
Thank you
submitted by /u/Revolutionary_End570
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