My insurance said a procedure is investigational, but my doctor says its standard of care?

As a physician, I am frequently asked by my patient why a procedure that is considered standard medical treatment might be denied as investigational.

Even more intriguing is why some private insurance companies will approve a particular procedure under one plan, and will disapprove the procedure as investigational under a different plan, although both are administered and owned by the same company.

The reality is that health care dollars are limited and insurance companies apply a cost benefit analysis to their coverage decisions, tempered against a possible public relations backlash, and the frictional hassle of dealing with the State insurance Board appeal and scrutiny.

Always confer with your physicians office, and your insurance carrier. Your appeal rights are time limited, so pay close attention to any requests for information.

Unless you have signed an ABN [Advanced Beneficiary Notice], you may not have to pay a bill that the insurance company denies as investigational.

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