Knee replacement, bariatric surgery, spinal fusion, or other procedures denied? Get your surgery approved.
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Surgical denials are among the most commonly overturned insurance decisions. Know the rules that protect you.
Insurers must apply objective, evidence-based criteria when determining medical necessity for surgery. They are required to disclose which guidelines they used (e.g., MCG, InterQual, Milliman). If their criteria are more restrictive than AAOS, NASS, ASMBS, or other specialty society guidelines, that discrepancy is the foundation of a strong appeal.
Many surgical denials cite failure to complete conservative treatment first — but insurers must specify exactly what they require and for how long. If your doctor has documented that you've already tried conservative care, or that conservative treatment would be harmful or futile in your case, the insurer's position is medically unsupportable and appealable.
Insurers frequently approve a procedure but deny the inpatient stay, insisting the surgery be done outpatient. This is a separate, appealable decision. If your surgeon certifies that inpatient care is medically necessary — due to your age, comorbidities, or surgical complexity — you have grounds to require the insurer to cover inpatient admission.
ACA-compliant plans must offer independent external review for all adverse benefit determinations, including surgical denials. You have the right to have a board-certified surgeon in the relevant specialty — not the insurer's reviewer — assess your case. External reviewers reverse insurer decisions more than 40% of the time for surgical cases.
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