Appeal guide · Surgery

Surgery denials

Surgical denials are issued before the procedure (prior authorization) or after (claim denial). Both have appeal paths. The strategy depends on which.

What gets denied

Bariatric surgery (gastric sleeve, bypass, RYGB)
Orthopedic — knee, hip, shoulder replacement
Spine surgery (fusion, decompression)
Cardiac (CABG, valve replacement, ablation)
Reconstructive and plastic surgery deemed cosmetic
Bilateral mastectomy and reconstruction

Common denial reasons

Plan claims procedure is 'not medically necessary'
Conservative therapy (PT, weight loss, etc.) not documented
Wrong CPT/ICD coding submitted by surgeon's office
Carrier deems procedure 'experimental' or 'investigational'
Pre-existing condition exclusion (rare under ACA)

How we approach the appeal

Force the carrier to disclose the clinical criteria they used. Have the surgeon write a letter of medical necessity addressing each criterion. Attach prior conservative-therapy documentation. Request a peer-to-peer review with the plan's medical director.

Filing window

Pre-service (prior auth) appeals: 30 days standard, 72 hours urgent. Post-service claim appeals: 30-60 days. Internal appeal must usually be filed within 180 days of denial.

Typical recovery

$5,000 – $150,000+ depending on procedure

Documents we'll ask for

· The denial letter
· Insurance card (front + back)
· Surgeon's pre-operative notes
· Imaging reports (MRI, X-ray, CT)
· Conservative-therapy records (PT, medication trials)

Got a surgery denial?

Two-minute micro intake. We confirm fit and reply within one business day with the right path for your situation.

Start Your Appeal

This page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.