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.
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.
$5,000 – $150,000+ depending on procedure
- · 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?
Free 24-hour review. Send the denial letter and we'll tell you whether your case has a shot and what the next step would look like.
Start my appealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.