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Old 10-19-2010, 09:03 AM   #1
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Question Anthem denied OATS procedure - Advice on Appeal

Hello,

Anthem denied my OATS procedure. Their letter says it is considered experimental and not medically necessary. They will cover OATS for the knee, but not the ankle.

I have read threads on here where people have the same issue and it eventually is covered after appeals.

They paid for everything else (operating room, hospital, anesthethia, Home health care, PT, etc.) but not the actuall surgeons fee, which is $4,700.00.

I called my doctor's office and he is going to write a letter on why it was necessary and ask for a peer review.

My lesion was 1.4cm and he told me right off the bat that arthroscopic would not work. This was the only solution.


I think I have read where I can only appeal once. Any advice on what I need to gather together before I appeal the claim?

Thanks in advance for any advice.

Terri

Last edited by Terrilo45; 10-19-2010 at 09:03 AM.

 
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Old 10-19-2010, 01:22 PM   #2
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Re: Anthem denied OATS procedure - Advice on Appeal

Right now I'd wait and see what happens after your dr. writes the letter. He may have better luck, esp if he asks for a peer review which is necessary in this case.
Hang in there!
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Brostrom x2, peroneal tendon repair x2, Peroneal subluxation, PTT tendon repair, microfracture x5, OATS, Distraction arthroplasty, ORIF talus & fibula, subtalar fusion, ankle replacement (failed)
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