Surgery was denied for lack of conservative treatment. How do I appeal?
A conservative-treatment denial means the plan thinks required non-surgical care was not tried or not documented. Appeal by listing each conservative measure with dates, duration, result, contraindications, and the surgeon's explanation of why more delay is not medically appropriate.
What to do, in order
- Step 1
Get the surgery policy
Find the exact conservative-treatment requirement: PT duration, injections, medication classes, imaging, BMI, smoking status, or specialist evaluation.
- Step 2
Create a treatment table
For each therapy: start date, end date, dose or frequency, response, side effects, and why it failed or was contraindicated.
- Step 3
Include objective findings
Imaging, exam deficits, functional limits, pain scale, and failed prior procedures help show surgery is not premature.
- Step 4
Have the surgeon address risk of delay
A statement that more conservative care is unlikely to help or could worsen outcome is key.
The deadline that applies
At least 180 days to appeal on employer and ACA plans; pre-service surgery appeals are generally decided within 30 days, urgent within 72 hours when delay risks serious harm.
Calculate your date →Documents to gather
- Surgery denial
- Plan surgery policy
- Conservative-treatment timeline
- Imaging and exam findings
- Surgeon letter
Go deeper
Related questions
Can contraindicated treatment count as tried?
It can count as not required if the clinician explains why it is unsafe or inappropriate.
What if the plan requires PT but I got worse?
Document worsening and ask the clinician to explain why continuing PT is not medically appropriate.
Should I send every therapy note?
Send the key notes and a clear timeline. The appeal should make the criteria easy to verify.
Sources
Share your denial and ask our team about appeal preparation and filing support. $0 upfront. Review the fee and terms before deciding. Apellica is not a law firm and cannot guarantee an outcome.
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