Endoscopy Insurance Denial Attorney in California
An endoscopy can be ordered to help diagnose or treat an array of digestive issues, including ulcers, gastritis, and inflammatory bowel disease. It can also be used to detect or stage upper digestive tract cancer, identify a source of bleeding in the digestive tract, or treat blockages or narrowing of the digestive tract. Unexplained weight loss, heartburn, chronic diarrhea, or constipation can benefit from an endoscopy as well. If your doctor has ordered an endoscopy, it is because he or she believes you have a medical condition that requires an endoscopy to properly diagnose.
This makes it especially disheartening to have an endoscopy denied by insurance. If your insurer has denied your endoscopy, it is normal for you to feel frustrated, even angry. It can be extremely helpful to speak to a knowledgeable, experienced insurance denial attorney from the Law Offices of Scott Glovsky. While it may seem easier to just give up, your insurer should not be allowed to deny necessary medical treatments, and attorney Scott Glovsky will make sure the insurer is held accountable.
What Is an Endoscopy?
An endoscopy uses a scope that goes inside your body to take photos or videos of organs and other body structures. There are many different types of endoscopy procedures, including an upper endoscopy, a colonoscopy, and a laparoscopy. A long, thin, flexible tube with a tiny camera is placed inside the body until it reaches the area that needs to be checked. Researchers are constantly working on developing new technologies to make endoscopies less invasive.
A capsule endoscopy is one example; the patient swallows a vitamin-sized capsule with a camera inside. As the capsule travels through the esophagus, stomach, and small intestine, it takes pictures that allow the doctor to diagnose bleeding or tumors. The most well-known type of endoscopy is a colonoscopy, used to detect colon cancer. While endoscopies were initially used only to examine organs, they are now used to fix medical problems like a bleeding stomach ulcer.
Endoscopes can also seal wounds, inject medicine, drain fluid, find infectious diseases, remove damaged tissues or tumors, fix blockages, place stents, and perform surgeries. Depending on the procedure, endoscopies typically take 30 minutes to two hours. Most are day surgeries, although sometimes an endoscopy requires an overnight hospital stay. Sedation and anesthesia ensure the procedure is pain-free. Because there are so many medically necessary reasons for an endoscopy, you may not know where to turn when it is denied by insurance.
Why Could an Endoscopy Be Denied by Insurance?
Like any medical procedure or treatment, an endoscopy claim could be denied because it contained insufficient information or errors. These issues can be fixed, and the claim can be resubmitted to the insurer. An endoscopy claim might be denied if the insurer required prior authorization and that authorization was not obtained. In rare circumstances, the endoscopy could be specifically excluded from your plan.
Much more commonly, an endoscopy is denied under the guise that it is not medically necessary or is investigational or experimental. These are often “code words” for “we don’t want to pay for it.” More expensive procedures and treatments are far more likely to be denied by insurers than less expensive procedures and treatments. Depending on where you live and the type of endoscopy your doctor has ordered, the cost could be between $1,500 and $4,000 for a day procedure or more for an endoscopy that requires a hospital stay. If your endoscopy procedure has been denied, do not give up; options are available.
What Should You Do if Your Endoscopy Is Denied By Your Insurer?
If your doctor believes an endoscopy is necessary but your insurer has denied the service, you can first file an internal appeal. An internal appeal asks your insurer to take another look at the claim and reach a different decision. Including a letter from your doctor with your internal appeal forms can be beneficial. This letter will state in detail why the endoscopy is necessary in your case and how it will improve your health outcomes. If your insurer continues to deny the procedure, you can file an external appeal.
An external appeal is filed with a neutral third party who will look at all the information and decide whether your insurer must pay for your endoscopy. The decision of this third party is legal and binding. If the decision is that your insurer should pay for the endoscopy, then the insurer must pay for the procedure. Unfortunately, fewer than one percent of all denied claims are appealed, yet when they are appealed, almost half of the decisions are overturned, and the insurance company is made to pay for the treatment.
Which Insurance Companies Are Most Likely to Deny an Endoscopy Claim?
Any insurer can potentially deny an endoscopy claim, although some may be more likely to do so than others. Some insurance companies may see an endoscopy as a preventative measure and decline to cover it. There is currently a wide variability in insurance coverage for endoscopies.
Some insurers provide extensive coverage, while others provide limited or no coverage at all. There may be a requirement for prior authorization, or the procedure can simply be deemed “medically unnecessary.” Some of the California insurers that could deny an endoscopy include:
- Anthem Blue Cross
- Blue Shield
- Health Net
- Kaiser
- Cigna
- Aetna
- Medi-Cal Managed Care Plans (Anthem Blue Cross, Promise Health Plan, Health Net, Molina)
How an Experienced Insurance Denial Lawyer from the Law Offices of Scott Glovsky Can Help
You need highly qualified legal assistance if you have received an endoscopy insurance denial. Attorney Scott Glovsky began his career on the other side, working for big insurance companies, and this experience and knowledge significantly benefit his clients. Scott is nationally recognized as an advocate for the rights of the injured and insurance policyholders. Attorney Glovsky will tirelessly fight for justice on your behalf, never giving up or giving in. Contact the Law Offices of Scott Glovsky to schedule a consultation.