# Need advice on how to appeal denied surgery **URL:** \ **Category:** Miscellaneous and Personal Stuff I Must Share\ **Created:** [September 23, 2026, 5:14pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314 "2026-09-23T17:14:06Z")\ **Posts on this page:** 12\ **Page:** 1
**Author:** ![Exapno\_Mapcase](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/exapno_mapcase/32/1051_2.png) [@Exapno\_Mapcase](https://boards.straightdope.com/u/Exapno_Mapcase)\ **Post date:** [September 23, 2026, 5:14pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/1 "2026-09-23T17:14:06Z")
I was scheduled for a third spinal surgery, which got cancelled one day before because the insurance company denied it. My surgeon is making an appeal, which is dragging on. I received paperwork from both my insurer (Excellus) and Medicare about appeals. Never having gone through the process I was hoping I could get advice from those who have. Excellus offers an appeal basically asking for my reasons for appealing and any supporting evidence. Medicare uses C2C Solutions. I have a right to a hearing with an Administrative Law Judge (ALJ) or Attorney Adjudicator (AA). Can be done over the phone. Is there a reason to prefer one over the other? Should I do both? Does doing one conflict with the other? What’s the difference between an ALJ or AA? What is the best evidence? How should it be presented? What works? The paperwork informed me of phone numbers for the State insurance department and for Excellus and Medicare. I’ll be calling them, but I expect they can only say “these are your rights and options” stuff I already know. Anything that might help would be welcome. ---
**Author:** ![filmore](https://avatars.discourse-cdn.com/v4/letter/f/7993a0/32.png) [@filmore](https://boards.straightdope.com/u/filmore)\ **Post date:** [September 23, 2026, 5:18pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/2 "2026-09-23T17:18:56Z")
What about switching to a new insurance provider? The enrollment period for ACA marketplace insurance is coming up on Nov 1st. Maybe you could find another provider who would be more likely to approve the surgery. ---
**Author:** ![Exapno\_Mapcase](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/exapno_mapcase/32/1051_2.png) [@Exapno\_Mapcase](https://boards.straightdope.com/u/Exapno_Mapcase)\ **Post date:** [September 23, 2026, 5:22pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/3 "2026-09-23T17:22:41Z")
That’s always a possibility. But any new insurance wouldn’t go into effect until 2027, and then the process would have to start all over. And there’s no way of knowing in advance who to go with that would give approval. ---
**Author:** ![DavidNRockies](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/davidnrockies/32/6279_2.png) [@DavidNRockies](https://boards.straightdope.com/u/DavidNRockies)\ **Post date:** [September 23, 2026, 5:23pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/4 "2026-09-23T17:23:39Z")
Is this your carrier? > **[Grievance and Appeals | Excellus BlueCross BlueShield](https://www.excellusbcbs.com/plans/medicare-advantage/enroll/grievance-appeals)** > > There are two different types of complaints you can make. Learn how to file an appeal for a denied claim or file a complaint about quality of care. If so, would this apply, and is your Surgeon taking this approach? > [@](#): > > Expedited appeal > An expedited appeal may be filed if it is determined that waiting the standard time frame may seriously jeopardize your life or health or your ability to regain maximum function. > > If your appeal is about a Part D drug that you have not yet received, we will make a decision as expeditiously as possible, but not later than seventy-two (72) hours of receiving the appeal request. We will give you the decision sooner if your health condition requires us to. > > If your appeal is about Part C medical care or services you have not yet received, we will make a decision no later than seventy-two (72) hours of receiving the appeal request, but we will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to fourteen (14) more days to make our decision. > > Where to file an expedited appeal (Level 1) with our plan > Mail: Excellus BlueCross BlueShield, Customer Advocacy Unit, PO Box 4717, Syracuse, New York 13221 > Call: 1-877-883-9577 (TTY711) > Fax: 1-315-671-6656 ---
**Author:** ![DavidNRockies](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/davidnrockies/32/6279_2.png) [@DavidNRockies](https://boards.straightdope.com/u/DavidNRockies)\ **Post date:** [September 23, 2026, 5:25pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/5 "2026-09-23T17:25:28Z")
Also … > **[Reconsideration by the Medicare Advantage (Part C) Health Plan | CMS](https://www.cms.gov/medicare/appeals-grievances/managed-care/reconsideration-advantage-health-plan-part-c)** > > Appeal and reconsideration > If a physician requests the expedited reconsideration, plans are required to expedite the request. ETA: > Once the plan receives the request, it must make its decision and notify the enrollee of its decision as quickly as the enrollee’s health requires, but no later than 72 hours for expedited pre-service benefit or Part B drug requests, 30 calendar days for standard pre-service requests, 7 calendar days for standard Part B drug requests, or 60 calendar days for payment requests. I know it refers to “pre-service requests,” but the text comes under the heading of: “How a Health Plan Processes Reconsideration Requests,” and … since you haven’t _had_ the recommended/needed procedure … [NB: maybe that’s obvious, but the wording had me a bit uneasy…] ---
**Author:** ![Exapno\_Mapcase](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/exapno_mapcase/32/1051_2.png) [@Exapno\_Mapcase](https://boards.straightdope.com/u/Exapno_Mapcase)\ **Post date:** [September 23, 2026, 5:46pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/6 "2026-09-23T17:46:31Z")
Yeah, that’s the boilerplate they sent me. ---
**Author:** ![snowthx](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/snowthx/32/10660_2.png) [@snowthx](https://boards.straightdope.com/u/snowthx)\ **Post date:** [September 23, 2026, 6:20pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/7 "2026-09-23T18:20:58Z")
I think the best way to get an appeal pushed thru swiftly is thru your doctor. The denial stated “not enough info” or somesuch to make a decision, so your doctor needs to follow-thru and provide the necessary documentation that justifies the surgery. Ride your doctor about this, and in parallel, call the insurance and clarify what info is specifically needed, and then make sure your doctor knows this. The “evidence” the insurance is looking for is not from you, but from your doctor - they need to get on the case as a priority, and the way to ensure that is happening is to bug the doctor. Going thru an external review board (external to your insurance and doctor) is likely going to take a while, and may be a “last resort” type of thing. ---
**Author:** ![Roderick\_Femm](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/roderick_femm/32/14875_2.png) [@Roderick\_Femm](https://boards.straightdope.com/u/Roderick_Femm)\ **Post date:** [September 23, 2026, 8:30pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/8 "2026-09-23T20:30:50Z")
> [@Exapno\_Mapcase](#): > > Excellus offers an appeal basically asking for my reasons for appealing and any supporting evidence. > > Medicare uses C2C Solutions. I have a right to a hearing with an Administrative Law Judge (ALJ) or Attorney Adjudicator (AA). Can be done over the phone. > > Is there a reason to prefer one over the other? Should I do both? Does doing one conflict with the other? What’s the difference between an ALJ or AA? Is your Excellus insurance the usual sort of “Medicare Gap” insurance, designed to help pay the 20% that Medicare does not cover? If so, did both deny the surgery? Since they both contribute, they both need to be dealt with. I would start with Medicare first, because as long as they deny the operation, your gap insurance isn’t even consulted. If this isn’t your insurance arrangement, never mind. Anyway, if and when you try the Medicare appeal, I would in general think an ALJ better than an AA, unless they have exactly the same qualifications. Full disclosure, my father was an ALJ for worker’s comp for 20 years, and I was always impressed with how rigorous they were; his decisions were subject to appeal to state court. It might be worthwhile to find out if Medicare ALJ decisions can be further appealed. Good luck. The doctor’s office may not be well-staffed in support people able to write such appeals, which may be why it is taking them a long time. ---
**Author:** ![PastTense](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/pasttense/32/14550_2.png) [@PastTense](https://boards.straightdope.com/u/PastTense)\ **Post date:** [September 23, 2026, 10:55pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/9 "2026-09-23T22:55:52Z")
> [@Exapno\_Mapcase](#): > > And there’s no way of knowing in advance who to go with that would give approval. Remember there are two types of Medicare plans: the Supplements (like F and G) and Medicare Advantage. The supplements automatically approve anything Medicare approves. The Medicare Advantage plans are the ones usually denying coverage–that is basically how they appear to be offering better value–because they deny a lot of treatments. So you want to choose a Supplement plan. We have some experts on Medicare plans here; perhaps they will comment. ---
**Author:** ![Exapno\_Mapcase](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/exapno_mapcase/32/1051_2.png) [@Exapno\_Mapcase](https://boards.straightdope.com/u/Exapno_Mapcase)\ **Post date:** [September 23, 2026, 11:08pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/10 "2026-09-23T23:08:42Z")
I do in fact have a Medicare Advantage plan. However, if I am correctly reading the paperwork sent me, Medicare itself issued a denial. ---
**Author:** ![PastTense](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/pasttense/32/14550_2.png) [@PastTense](https://boards.straightdope.com/u/PastTense)\ **Post date:** [September 23, 2026, 11:53pm UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/11 "2026-09-23T23:53:52Z")
Read this about the types of appeals in a Medicare Advantage plan: > **[Appeals in Medicare health plans](https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans)** ---
**Author:** ![Exapno\_Mapcase](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/exapno_mapcase/32/1051_2.png) [@Exapno\_Mapcase](https://boards.straightdope.com/u/Exapno_Mapcase)\ **Post date:** [September 24, 2026, 12:34am UTC](https://boards.straightdope.com/t/need-advice-on-how-to-appeal-denied-surgery/1033314/12 "2026-09-24T00:34:56Z")
I’m asking about level 3 appeals. The format is in the boilerplate I’ve already received. I’m hoping that somebody who has been through the process will tell me their experiences.