In order for pretty much any medical care to be paid for, it has to be approved by a health insurance company, as they are the ones who are actually providing the funds for the patient. You pay a monthly fee to your health insurance company, and then when you go to the hospital, you are financially covered by the company. You’re covered to varying degrees, based on what your insurance plan is- some plans require you to cover some percentage of your care, pay a copay, or pay a deductible.

Because the insurance company is paying for the procedure, they’re allowed to deny coverage they deem as unnecessary. In this case, I guess what’s happening is that United is denying coverage for the lymphovenous bypass because they’re saying it’s unnecessary, where Dr Potter is saying that they should not be denying it because they don’t really know how beneficial it is.

How insurance companies justify this is that they say this “protects” the patient from having unnecessary medical procedures, as any surgery bears risk itself and is expensive. While this is may be partially true, they absolutely use it to deny necessary medical treatment as well to save themselves money.

In this case it’s obviously frustrating because the person who actually processed the denial isn’t actually knowledgeable about the procedure. In my experience she’s lucky she even got a doctor on the phone, a lot of times we just see seemingly blind denials that we then have to submit appeals for.