My Otolaryngologist, diagnosed that I have "polyps" (sinus) by doing x-ray and CT scan and told to have a surgery and his office took a pre-certification from my insurance and I had Functional Endoscopic sinus surgery and Septoplasty on 3/10/2015.
At the beginning on 4/14/2015 insurance company asked Doctor's office for additional documents, like history, treatment progress notes, Lab testing result and not sure if Doctor's office sent all documents.
During the first claim, Insurance company declined saying medical necessity not established "procedures may not be approved, per established medical guidelines, as there is no documentation of a failure of maximum medical therapy, including : allergy assessment, Nasal Lavage, Trial of 2 or more antibiotic and nasal steroids" -- this seems Doctor misguided me to go for surgery.
During the second claim, insurance declined again by saying "the surgery was not medically necessary" according to AMA (American Medical Association) policy H-320.953.
This time insurance involved a third party insurance company, and they too concur with my insurance company.
Now Doctor's office sent me a bill to pay.
Most physician offices have patients when they become patients sign a form that the patient is liable for all expenses not covered by insurance. If that is the case you are liable for the expenses of the procedures if you consented to have same.
I think you are probably asking if this is malpractice and the answer is, there is no way to know based on what you've told us. Unfortunately, most medical insurers do not use medical professionals to make the decision about "medical necessity" so that statement isn't necessarily good evidence that the procedure wasn't needed. I would appeal the decision with the insurance company and have them give you the identity and qualifications of the person who made the decision. Only if that is a doctor would I then look to whether this is malpractice.
This answer is provided as a public service for informational purposes only. Providing this information does not create an attorney-client relationship. As with all legal matters, you should contact an experienced attorney in your geographical area to discuss the law specific to your state. For more information, see www.hendricksonlaw.com.
File a complaint with your state's insurance commisiioner.If they pre certed not sure why they'd fart around laeter.
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