Any idea on how a health insurance company determines eligibility of surgical procedure recommeded by one's doctor?

I know with all of our daughter’s surgeries they have to be pre-qualified. We had a nurse who worked for the insurance company who advocated for our daughter’s care at some points because insurance didn’t deem certain things as necessary. She told us that there are different doctors who work for the insurance company and determine the grey areas. She said some are more leniant than others because it’s whatever their preference is. Our insurance is Blue Cross, so I’m not sure if it is different elsewhere.

I think that you can call the insurance on your own and ask them if what you plan on doing falls into something they would pay for.

If your doctor sends in paperwork and requests it explaining why you need this, that might carry more weight also. Good luck!

It’s been a while since I worked for an HMO, but generally the provider (the doc) will seek a “pre-auth”(orization) from the insurer. It will either be approved or denied. If it’s denied, you have the right to file an appeal with the insurer. There may be options for a 2nd appeal. If that gives you no remedy, you can file an appeal with the state’s Department of Insurance, which I believe is the final authority. Generally, states mandate that insurers cover all “medically necessary” care. Medical Necessity has a legal definition that is probably spelled out in your Member Handbook, and definitely on your state’s DOI Web site. I don’t have firsthand experience of approval/denial rates or tendencies, but I think you have many opportunities for remedy if you need them.

If you haven’t sought the opinion of a pain specialist, you should do that as well.

Good luck.

Found on Family doctor.org “Insurance companies determine what tests, drugs and services they will cover. These choices are based on their understanding of the kinds of medical care that most patients need. Your insurance company’s choices may mean that the test, drug or service you need isn’t covered by your policy.” “Take the time to read your insurance policy.” “Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not.” This does not mean you can’t have the procedure your doctor recommends, it just means you have to pay for it out of your own pocket.

So far almost all procedures our family members have undergone were pre-certified, generally by either the doctor’s staff or by the hospital. The only one that was refused was a period in a residential psychiatric treatment facility. The excuse given was that “we hadn’t yet exhausted all community resources” (translation: we hadn’t had him arrested). I appealed and the appeal was turned down. I appealed to the next level, and it was approved. It took a lot of writing and document gathering – I had to fax 80 pages to the appeals board.

I know two people who were turned down by insurance companies because their treatment was considered “experimental.” I know that both were eventually successful at getting the treatments covered. I don’t know how one was able to do it, but the other hired a lawyer and sued. Good thing, too, because it was a treatment for cancer and it seems to have worked as she has been in remission over five years, when prior to that she was at Stage 4.

However, before you get into a dither about this, you might consider asking your insurance company, or even better, having your doctor’s office do it (so all the necessary codes get put in the necessary places). The doctors that perform this procedure probably know how best to get it covered.

My husband has had experimental surgery ore authorized in the past.
I have often wondered if treatment authorization is influenced my who make the request.
Husband had prominant neurosurgeons making the request for him.
On the other hand, I have a local eye doctor treating me for an eye condition requireing three new pair of glasses this year. I have had to fight my insurance company to cover the cost of the new glasses.

Thank you all so much, much lurve.

The doctor’s office is seeking the pre-certification, so at least I don’t have to worry about that aspect of it. I plan on having the procedure no matter what, but it will have to be on a super stretch layaway plan if insurance doesn’t cover it.

If they don’t approve it the first time know that you can appeal, like @kevbo said, sometimes it just takes a little persistance with these companies.

I work for a health insurance company. The way approvals are determined is based upon the records that are submitted by the doctor. These are reviewed by a team of doctors and/or nurses (depending upon the procedure/specialty) and a determination is made on a medical basis as to the appropriateness, and if the plan covers that treatment/type of treatment. You have the right to appeal. Grievance and appeal happens through your state’s DOI department. When you receive a letter from your insurance company notifying you as to wether or not you’re covered, the letter will explain the G&A process. It’s usually also on your EOB statements.

Make sure your read your certificate of coverage, and understand what it says. This is your contract with your insurance carrier, and determines plan coverage.

I should also point out that, if you have health insurance coverage through your employer, the level of coverage that you have is dependent on the choices your company makes for coverage options. A given health insurance company may have hundreds of plan choices. The rates your group pays is a balance of plan choice, and claims history for the group. If you work for a company of 100+ employees, your claims get paid from the pool of premiums contributed by your employer and the employees. This works out because in an average year, 60% of the population uses $700 or less in healthcare services.