You have a surgery scheduled, your doctor has recommended the procedure, and you've started making arrangements. Then you learn that your insurance company has denied coverage.
You may be wondering whether your surgery is canceled, whether your surgeon can challenge the decision, or whether you're expected to resolve the problem yourself.
An insurance denial doesn't always mean the decision is final. But the next steps depend on why coverage was denied, what type of insurance you have, and how soon your surgery is scheduled.
Not every insurance denial means the same thing.
If you haven't had surgery yet, the denial may involve prior authorization—a decision about whether your insurance plan will approve the requested procedure before it happens.
If you've already had surgery, the denial may involve a claim, meaning the insurer has decided not to pay some or all of the billed charges.
These situations have different implications.
For a scheduled surgery, ask your insurer:
If the insurer says the request is still being reviewed, that's different from a denial. See What If My Surgery Insurance Authorization Is Still Pending?.
Insurance companies can deny a request for several reasons.
Common possibilities include:
The reason matters because it determines what can happen next.
A missing document may be handled differently from a disagreement about whether surgery is medically necessary.
Don't assume you know why the procedure was denied. Ask for the exact reason from the insurer.
If your surgery hasn't happened yet, a practical starting point is usually the surgeon's office, particularly the staff member who handles insurance authorizations.
Explain what you've been told and ask whether the office has received the denial.
The office may be able to tell you whether it plans to submit additional records, correct an error, request reconsideration, or pursue an appeal.
You should also contact your insurance company to understand the decision directly.
Questions for your surgeon's office:
Questions for your insurance company:
Before ending each call, confirm who is responsible for the next action.
Often, the surgeon's office plays an important role.
Depending on the reason for denial and the insurer's procedures, the office may be able to:
Not every denial can be resolved through these steps, and not every insurance plan offers the same process.
Ask the office what action it intends to take, when it expects to take it, and when you should follow up.
It's also worth asking whether you need to participate in the appeal yourself.
Not automatically.
An insurance denial and a surgery cancellation are two different decisions.
Your surgeon may still recommend the procedure even if the insurance company has declined coverage. However, the surgical facility may have requirements about authorization or payment before proceeding.
If your surgery is already scheduled, contact the scheduling or authorization team and ask:
"Does this denial affect my surgery date, or are you still working to resolve the authorization?"
Don't assume the procedure is canceled just because you received a denial. But don't assume it will proceed as scheduled, either.
If the date is approaching and you haven't received a clear answer, follow up promptly.
And before considering paying for the procedure yourself, request a written estimate and understand the potential financial responsibility. Insurance approval and the amount you may ultimately owe are separate questions.
Many health insurance plans provide an appeals process that allows you to challenge a coverage decision.
An internal appeal asks the insurance company to reconsider its decision.
For eligible denials, an external review allows an independent reviewer to evaluate the insurer's decision.
The process and deadlines depend on your coverage.
For many Affordable Care Act-regulated private health plans, patients generally have at least 180 days after a denial notice to request an internal appeal. Medicare Advantage and other coverage programs can have different deadlines and procedures.
Use the instructions in your own denial notice rather than assuming a general deadline applies.
Your appeal may benefit from supporting documentation from your surgeon, particularly when the denial involves medical necessity.
If you're unsure where to start, ask the insurer how to initiate an appeal and whether the surgeon's office can submit information on your behalf.
If your surgery is approaching, tell your surgeon's office immediately.
Some insurance plans offer an expedited appeal when waiting for the standard review process could seriously jeopardize a patient's health or ability to regain function.
A scheduled surgery date alone doesn't necessarily qualify a case for expedited review.
Your treating clinician can help determine whether there is a medical basis for requesting faster consideration.
Ask:
"Does my situation qualify for an expedited review, and who needs to request it?"
If the standard timeline could affect your care, your surgeon's office should know so the clinical team can assess the situation.
If your condition worsens or you have urgent medical concerns, contact your healthcare team promptly rather than waiting for an insurance decision.
A denial after an internal appeal may not be the end of the process.
Depending on your health plan and the reason for denial, you may be eligible for external review.
External review involves an organization independent of your insurer. If the denial is overturned through an applicable binding review process, the insurer must follow that decision.
Your final denial notice should explain the next steps available under your plan.
You may also be able to get help from your state's Consumer Assistance Program, state insurance department, or the appropriate Medicare assistance resources.
Not every type of denial is eligible for external review, so confirm the rules that apply to your coverage.
Insurance problems can involve several calls and different people working on the same issue.
A simple record can help you avoid repeating information and identify what still needs to happen.
Keep track of:
You don't need to understand every insurance rule. The immediate goal is to know what was denied, who is working on it, and what happens next.
Preparing for surgery involves a lot of small but important steps. Download the free SurgiNav Surgery Prep Checklist to stay organized and feel more confident before your procedure.
If your surgery was denied by insurance, start by getting the specific denial reason and confirming whether your surgery date is affected.
Contact your surgeon's authorization team and your insurance company. Find out whether the problem can be corrected, whether additional information is needed, or whether an appeal is appropriate.
Most importantly, establish who is responsible for the next step and when you should expect an update.
An insurance denial can create uncertainty, but you don't have to navigate every part of the process without guidance.
Preparing for surgery can feel overwhelming, but you don't have to remember every detail on your own. Download the free SurgiNav Surgery Prep Checklist to stay organized, avoid common mistakes, and feel more confident before surgery day.
Download the Free Surgery Prep ChecklistThis article provides general educational information and is not a substitute for medical advice. Always follow the instructions provided by your healthcare team.
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