Client Receives Pre-Approved Surgery After Multiple Denials

The Client

eLearning Program Provider with over 30 enrolled employees

The Challenge

An employee who had been undergoing treatment for gender dysphoria was in the process of scheduling their final transition surgery. The insurance carrier provided criteria the employee needed to meet to cover the surgery. Although the employee met every guideline, their provider’s prior authorization request was still denied due to “conflicting language between the employees plan benefits and the provider’s contract” – so the procedure would not be covered.

The Solution

The employee contacted their Caravus Advocate, who immediately sent in an appeal. After several appeal requests and conversations with the insurance carrier’s legal team and board of doctors, the denial was ultimately overturned.

The Outcome

The employee’s surgery was fully covered by their insurance, successfully completing their transition.