Ever file an appeal because of denial of coverage?

[Anonymous]

I had a colonoscopy last year and they used "monitored anesthesia", not by my request, but by routine procedure/doctor's request. Insurance wants me to pay the $460 extra for this, as it is "not medically necessary". They feel anesthesia (just the IV sedation part is all that should be done) for this procedure doesn't require the extra leads attached to the patient's body to monitor heart rate/rhythm. I did an internal appeal and was denied coverage, and am going for the external review/appeal now. There is nothing extra that can be added to the stack of info already in the pile of papers they will get, including a wonderful letter from the gastroenterologist who did the procedure. I was going to add my own letter, nicely worded, that monitored anesthesia is routine at this facility, and that this is really an argument between the physician and the insurance, with me stuck in the middle. All the other patients at this place get monitored, so why the denial? Anyway, I am just wondering if anyone has added their own $0.02 as a last resort, and how'd it all turn out. The balance ($460) has already gone to a collection agency, too.

[Anonymous]

What ins co is this??? I've had colonoscopies and endoscopies and they ALWAYS use the leads for monitoring. I think you'd have a hard time finding an anesthesiologist who would put a patient undr w/o monitoring.

But if it were me I'd pay it and try to get the money back from ins if you can. It will mess up your credit therwise.

[Anonymous]

OP here. Insurance is Blue Cross PPO.
My husband is adamant that we don't pay anything right now. Since it's gone to a collection agency, he reasons the gastro clinic has sold the debt to the agency (and the clinic doesn't expect to get anything from us anyway). The collection agency hopes to recoup their costs plus whatever they get from us, so it's no longer between us and the clinic. This is really a problem between the clinic and insurer. We are in our 50's and have never had anything go to a collection agency before and our credit is basically perfect.
I just want to add my own letter to the pile going to the external review and wondering if anyone has done that. Otherwise they will just get the same info that the internal review board got.

[Anonymous]

I would request a copy of your plans benefits. It's usually called "summary plan description" which will specify everything your plan does and does bot pay for. It it is not listed as an exclusion, I would then go to the HR department that administers the plan. I had to do that in the past when our insurance company kept denying claims that were filed correctly (I had to pay out of pocket and then get reimbursed by them). The problem was solved within a day.