Any idea on how a health insurance company determines eligibility of surgical procedure recommeded by one's doctor?

Any idea on how a health insurance company determines eligibility of surgical procedure recommeded by one's doctor?
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1 Answer

Answer :

I know with all of our daughter’s surgeries they have to be pre-qualified. We had a nurse who worked for the insurance company who advocated for our daughter’s care at some points because insurance didn’t deem certain things as necessary. She told us that there are different doctors who work for the insurance company and determine the grey areas. She said some are more leniant than others because it’s whatever their preference is. Our insurance is Blue Cross, so I’m not sure if it is different elsewhere. I think that you can call the insurance on your own and ask them if what you plan on doing falls into something they would pay for. If your doctor sends in paperwork and requests it explaining why you need this, that might carry more weight also. Good luck!
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