What to Do If Your Surgery Was Denied (AI Guide)

Having a needed surgery denied by your insurance company is one of the most stressful experiences you can face. But surgical denials have a high overturn rate when properly appealed.

Why Surgeries Get Denied

1.**Not Medically Necessary**: The most common reason — insurer claims conservative treatment should be tried first

2.**Pre-Authorization Not Obtained**: Surgery performed without prior approval

3.**Experimental**: Insurer classifies the procedure as investigational

4.**Out-of-Network Surgeon**: Surgeon not in the insurer's network

Building Your Appeal

Medical Evidence

•Document all conservative treatments tried and failed

•Include imaging results (MRI, CT, X-ray) showing the condition

•Get letters from your surgeon AND referring physician

•Cite clinical guidelines from relevant specialty societies

Legal Arguments

•Medical necessity should be determined by treating physicians

•Insurer's desk reviewer cannot override in-person examination

•Cite Smith v. UHC and similar winning cases

Expedited Review

If your condition is urgent, request an expedited appeal. Insurers must respond within 72 hours for urgent situations.

Use our free generator for a surgery-specific appeal letter with all the right citations.

The Peer-to-Peer Strategy

Request that your surgeon speak directly with the insurer's medical director. Surgeons are often more persuasive than written appeals because they can explain the clinical nuances in real-time.