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Patient Julia Watson needs a surgical procedure that is not covered by her insurance plan. Answer the following questions related to the medical necessity of this procedure:

A. What must be obtained from Julia's insurance company to allow this procedure?

B. If Julia's insurance company's utilization protocol is different from that of the physician and the procedure is denied, what could be the action brought against the provider if this surgical procedure was, in fact, medically necessary?



Answer :

GinnyAnswer

Final answer:

To allow a surgical procedure not covered by insurance, pre-authorization is needed. If the procedure is denied despite medical necessity, appealing the denial and filing a complaint can be actions against the provider.


Explanation:

A. To allow the surgical procedure not covered by Julia's insurance plan, pre-authorization must be obtained from her insurance company.

B. If the insurance company denies the procedure despite its medical necessity due to a differing utilization protocol, the action that could be brought against the provider is appealing the denial and potentially filing a complaint with the insurance regulatory authorities.


Learn more about medical necessity and insurance coverage here:

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