Balloon Dilation Insurance Claim Denial

When you have faithfully paid your insurance premiums for years, having your insurer deny a necessary medical procedure can be devastating. If you have struggled with chronic sinus issues, you may be considering balloon dilation, also known as balloon sinuplasty. Balloon sinus dilation can stop the constant runny nose, inner ear problems, coughing, and congestion that make daily life more difficult than it has to be.

While OTC medications and at-home sinus remedies may produce temporary relief, balloon dilation can improve your quality of life, long-term. If your insurer has denied your claim for balloon dilation, you can get the help you need from the Law Offices of Scott Glovsky. Attorney Scott Glovsky has been fighting big insurance companies on behalf of his clients since 1999.

Page Contents:

• What is Balloon Dilation?
• Why Might a Balloon Dilation Procedure Be Denied by Insurance?
• What Can You Do if Your Balloon Dilation Claim is Denied?
• What Insurance Companies Are Known to Issue Balloon Dilation Insurance Claim Denials?
• How the Law Offices of Scott Glovsky Can Help

Balloon dilation can be used for sinus and nasal issues as well as during a cardiac catheterization procedure to inflate a narrowed valve. Ostial, nasal, and sinus balloon dilation procedures may be denied by insurance. Balloon sinuplasty is a minimally invasive procedure used to treat chronic sinus infections by inserting a small balloon through the nose and into the sinus cavity using a wire or probe. The balloon is then inflated to open the sinus passageway. Ostial balloon dilation inserts the balloon device across a narrowed sinus ostium, then inflates it.

Benefits of balloon dilation for nasal, sinus, or ostial relief include:

• Minimally invasive solution for chronic sinus problems
• No incisions
• Faster recovery
• Reliable results
• Outpatient convenience
• Far fewer side effects and complications

While an insurer may offer all sorts of reasons for denying a claim, including “not medically necessary,” “investigational,” and “experimental,” a common unstated reason for a denied medical claim is cost. The cost of a balloon dilation for sinus problems is between $3,000 and $7,000. Many insurers use the terms listed above for a balloon dilation insurance claim denial. This is despite the many benefits to patients in relieving chronic sinus issues.

If your balloon dilation claim is denied by your insurance company, it is important that you know such a denial does not have to be the end of your getting the medical treatment you need. You should have received a denial letter from your insurer that tells you why your claim was denied. Often, a claim may be denied because there were errors on the claim form that can be fixed and resubmitted. In some cases, your insurance company may have required a prior authorization.

If, however, your claim was denied because your insurer says the procedure is not medically necessary, or claims the procedure is experimental or investigational, you can fight this type of denial with the help of a strong legal advocate like Scott Glovsky. Scott can guide you through the process of filing an internal appeal, which is essentially asking your insurer to reconsider its decision. You may submit a letter from your doctor during an internal appeal that explains why the procedure is necessary. If you receive a denial to your internal appeal, you can file an external appeal with a neutral third-party, whose decision is binding on your insurer.

Although any insurer can deny a medical claim, some are more likely than others to do so. Patients with Anthem Blue Cross plans were routinely denied coverage for balloon sinus dilation, with the insurer calling the procedure investigational and deeming it not medically necessary.

Anthem required symptoms that lasted longer than12 weeks along with CT findings suggestive of obstruction qualified, while UnitedHealthcare required symptoms lasting longer than 12 weeks along with “bony thickening or bony remodeling.”

Anthem also required four consecutive weeks of antibiotics (a full month on antibiotics), inhaled steroids and allergy testing before it would agree to pay for balloon dilation. Any of the following California insurers may have denied your balloon dilation insurance claim:

• Anthem Blue Cross
• Blue Shield
• Health Net
• Kaiser
• UnitedHealthcare
• Aetna
• Medi-Cal Managed Care Plans

Attorney Scott Glovsky has helped hundreds of people who received a disheartening medical claim denial obtain the treatment or prescription drug they needed. Scott will seek out your doctor’s assistance to provide additional documentation to support the treatment. He will help provide evidentiary support that comprehensively explains the proposed treatment and why you need the treatment. Scott will then show that the treatment is a safe, medically accepted procedure for your condition. Do not give up if you have received a balloon dilation insurance claim denial; contact the Law Offices of Scott Glovsky.