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TKR Insurance rejected

loneshark64

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Hi my TKR is scheduled for next week. My doctor put in the request and the initial response from insurance was denied, not medically necessary. The doctor is now supposed to do a “peer to peer” call with the insurance company. The doctor’s office seems very confident that this is a formality and they will get the approval in all likelihood. They said the insurance will ask if I have had injections instead, which undid in the past and they did nothing.

Anybody have any advice on this? If it is perfunctory and we just have to jump through these hoops and they will say yes I am it sure what the point of an initial denial is.
 

Mutti3

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Have you gotten your denial letter yet? It should explain why you denied the knee replacement and why it didn’t meet medical necessity by the criteria used. Peer to peer are very common when denials are issued. What usually triggers a denial is the physician’s office not submitting enough clinical.
 
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loneshark64

loneshark64

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Nope not yet . Thanks for the feedback
 
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loneshark64

loneshark64

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I got the rejection letter in the mail. Reason had to do with whether I had had injections in the past. The Surgeon did a call with the insurance company and told them I had sunbird 10 years ago and steroids/hyaluronic acid 4 years ago. The good news is the insurance company approved the procedure and I am on for Wednesday the 15th!!

The only aspect of this I was nervous or worried about was the insurance covering it. Now I am relieved and ready to go.
 
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Insurances (Med and Disability) and what not can be very tricky. I avoided all shots/ injections as I was exploring options. I wanted as little of a trail that I had a knee issue until I was ready to address it. Glad to hear of your good outcome!
 

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