Help appealing denial of physical therapy

My insurance is denying physical therapist visit which is required by my Dr. pre-op.  They say it isn't a medical necessity but  it says I can send additional info but how do I know what was sent in originally by the Dr.'s Office?  My Dr.'s office say they have never had it denied by other insurance co's.  I don't know what to do can someone advise me on my next step? Do you think calling the customer service number would help me get additional info or they simply don't know what they are talking about?   Was just going to pay for it myself but they want $392.00 which seems like a lot if the insurance co's. usually pay for it.

 

I have never heard of a doctor require a visit to a physical therapist...can you tell me what his reasons are for this? What is your surgeon's name?

The only things doctors and insurance companies usually require are labs, clearance from your PCP (med eval), psych eval, history of weight, history of weight loss attempts, and list of co-morbidities.

I don't know for sure what it is for.  Some paperwork I had read in the info they gave me stated something about pre/post op movement.  I assumed it was to assess and help me set up a exercise program I would be able to do even with being overweight.     They have told me that they have had no problem with getting approval from any other ins. co.   His name is Dr. Max Hammer, with Memorial Bariatrics in Springfield, Il.   My insurance is Healthlink.  I have had nutritionist visits, psych. visit and all I have left was the physical therapist and labs before they would be sending the info to the ins. for approval for the surgery. 

Well, it seems you have to make the choice to pay for it on your own or go to another doctor that does not require it.

Certainly, you can appeal the denial but that will delay your surgery, unless you want to pay up front and just appeal for payback.

Hi there,

I haven't heard of requiring PT for bariatric surgery, that is very strange... reguardless,  $392 is WAY too much to pay yourself.  That may be what they bill to insurance, but they after adjustments and deductions they would get maybe $200 from the insurance company.  Ask if they have a "self pay" rate.  I work in physical therapy and for patients not using insurance we charge $125 flat fee.  My company has clinics all over Illinois, feel free to PM me if you would like me to help you find a place near you (not trying to advertise, just trying to be helpful!)