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Anthem denied OATS procedure - Advice on Appeal

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Old 10-19-2010, 08:03 AM   #1
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Question Anthem denied OATS procedure - Advice on Appeal


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.


Last edited by Terrilo45; 10-19-2010 at 08:03 AM.

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Old 10-19-2010, 12:22 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!
Brostromx2 peroneal tendon repairx2 Peroneal subluxation PTT tendon repair microfracturex5 OATS Distraction arthroplasty ORIF talus & fibula subtalar fusion ankle replacement (failed) TT fusion

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