What to do if anHMO denies needed surgery?

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What to do if anHMO denies needed surgery?

I had a bunion surgery on my right foot 1 year ago. In September of this year, my HMO denied my left foot surgery; the reason was “lack medical necessity. The documentation received does not support the need for the service because according to guidelines, a bunionectomy is indicated for patients who meet 6 criteria.My podiatrist submitted all necessary documents and requested another authorization. It was denied again for the same reason. He wrote a letter to the Physician Reviewer, describing my condition and submitted an appeal. It was denied for the same reason. I contacted my HMO and filed a grievance, and it’s still pending. Please advise if any lawyer can help me with this. And if not, what my next step should be.

Asked on December 2, 2010 under Insurance Law, California

Answers:

M.T.G., Member, New York Bar / FreeAdvice Contributing Attorney

Answered 10 years ago | Contributor

I would seek legal help here on a consultation basis.  You may need to sue the HMO to get them to pay for the operation and that may be more expensive than the operation itself.  Consumers of HMO's have certain rights.  That have the right to be advised of all forms of treatment regardless of whether or not their plan will pay for it; they have the right to appropriate treatment, ask questions, file complaints and file lawsuits.  So if you think that a letter from an attorney would make them cringe a bit and possible give in, do it.  Try and negotiate a flat fee with the attorney to write the letter and inquire on your behalf.  If it does not work then you will need to discuss the suit and that will be hourly (but ask if the fee is recoverable if you will).  Good luck.


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