Surgery denials
Surgical denials are issued before the procedure (prior authorization) or after (claim denial). Both have appeal paths. The strategy depends on which.
The rule that controls this: Medical-necessity review against the plan's own clinical criteria (MCG or InterQual), which the plan must disclose on request under ERISA § 503 and 45 C.F.R. § 147.136.
Last reviewed 13 September 2026 · General information, not legal or medical advice · Apellica is not a law firm
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)
Surgery denial? Let's appeal it.
Two-minute micro intake. We confirm fit and reply within one business day with the right path for your situation.
Surgery denials by insurer
What each plan tends to cite, and the rule that controls it.
This page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.