Insurance denied my surgery — what do I do?
Surgery denials are usually appealable. Here's the step-by-step.
Most surgery denials are based on the plan's medical-necessity criteria — and most are reversible with the right documentation. The denial letter you received MUST state the specific reason (federal law requires this under ERISA §503 + 29 CFR §2560.503-1). Read it carefully.
Steps
- Read the denial letter and find the SPECIFIC denial reason (not generic 'not medically necessary')
- Ask the plan for a copy of the specific internal rule, guideline, protocol, or other criterion it relied on (you have this right under ERISA §503)
- Get the surgeon's office to submit additional clinical documentation if the chart supports it
- Verify the internal-appeal deadline and instructions from the current notice and governing plan source
- If denied, request external review by an Independent Review Organization (ACA §2719) — the IRO's decision is binding on the plan
- DenialHelp can organize a draft using candidate governing and clinical sources for patient and clinician review
Frequently asked questions
Insurance denied my surgery — what do I do?
Most surgery denials are based on the plan's medical-necessity criteria — and most are reversible with the right documentation. The denial letter you received MUST state the specific reason (federal law requires this under ERISA §503 + 29 CFR §2560.503-1). Read it carefully.
What are the steps?
1. Read the denial letter and find the SPECIFIC denial reason (not generic 'not medically necessary'); 2. Ask the plan for a copy of the specific internal rule, guideline, protocol, or other criterion it relied on (you have this right under ERISA §503); 3. Get the surgeon's office to submit additional clinical documentation if the chart supports it; 4. Verify the internal-appeal deadline and instructions from the current notice and governing plan source; 5. If denied, request external review by an Independent Review Organization (ACA §2719) — the IRO's decision is binding on the plan; 6. DenialHelp can organize a draft using candidate governing and clinical sources for patient and clinician review
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