Q: BCBS Insurance exclusions for TMJ - denied the authorization for a surgery that is medically necessary - RS 22:1055
There is a document put out by BCBS Louisiana Policy #00583 that details when the surgery should be covered for TMJ due to medical necessity and BCBS is still denying it... what are my rights?
What can I do?
A Louisiana attorney could answer best, but your question remains open for three weeks. If the surgery pre-authorization you're talking about has provisions for appeal, you could discuss with your oral surgeon what an appeal would entail. At the very least, they would probably need to present supporting documentation as to why surgery is necessary. In general nationwide, TMJ surgeries are not always liberally authorized, so if your surgeon has had prior experience on denials for pre-authorizations, you could ask them if they have involved attorneys who are versed in litigating or arbitrating health care claims. Good luck
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