Diagnostic Claim Denied for 3-month old baby – appeal denied, what can we do?

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We are located in WI, USA.

We had our first baby in March. He was healthy for the most part, but after a couple months he started showing signs of stomach issues by eating a lot but screaming afterwards, having unnatural looking/smelling bowel movements, not sleeping well, etc.

We took him into the doctor who had a suspicion he had a milk intolerance. They did some allergy/bloodwork to apparently help determine the issue. The results were that he wasn’t really allergic to anything, but we switched him to special baby formula without milk in it anyway and he has done great ever since.

We received the EOB for the diagnostics in the mail a month later and it was over $1,500, not covered by insurance because it was “experimental or investigational in nature”. Nobody told us this wouldn’t be covered by insurance during the appointment, so it was really frustrating to see.

We appealed the claim through the doctor’s office/medical network, waited over a month and never heard anything. Apparently they lost the paperwork. We submitted the information again and once again never heard anything until we reached out and apparently the appeal was denied. It was recommended to appeal the code that was used. So we did that, and it, too, was denied.

This leaves us stuck with a $1,500 bill for a service that didn’t really do anything or tell us anything. I feel like the doctor’s office and the insurance company have been incredibly unhelpful during this whole process. We are also pretty sure our actual doctor was never involved in the process and didn’t do anything to help our case with the appeal, since we just worked with the different medical network departments.

Is there anything else we can try? Do we have any recourse, or do we now have to pay this $1,500 bill? This has been going on for almost 5 months now and it is even more frustrating that everything takes so much time to process. Any advice would be greatly appreciated. Thanks!

submitted by /u/TitanVex
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We are located in WI, USA. We had our first baby in March. He was healthy for the most part, but after a couple months he started showing signs of stomach issues by eating a lot but screaming afterwards, having unnatural looking/smelling bowel movements, not sleeping well, etc. We took him into the doctor who had a suspicion he had a milk intolerance. They did some allergy/bloodwork to apparently help determine the issue. The results were that he wasn’t really allergic to anything, but we switched him to special baby formula without milk in it anyway and he has done great ever since. We received the EOB for the diagnostics in the mail a month later and it was over $1,500, not covered by insurance because it was “experimental or investigational in nature”. Nobody told us this wouldn’t be covered by insurance during the appointment, so it was really frustrating to see. We appealed the claim through the doctor’s office/medical network, waited over a month and never heard anything. Apparently they lost the paperwork. We submitted the information again and once again never heard anything until we reached out and apparently the appeal was denied. It was recommended to appeal the code that was used. So we did that, and it, too, was denied. This leaves us stuck with a $1,500 bill for a service that didn’t really do anything or tell us anything. I feel like the doctor’s office and the insurance company have been incredibly unhelpful during this whole process. We are also pretty sure our actual doctor was never involved in the process and didn’t do anything to help our case with the appeal, since we just worked with the different medical network departments. Is there anything else we can try? Do we have any recourse, or do we now have to pay this $1,500 bill? This has been going on for almost 5 months now and it is even more frustrating that everything takes so much time to process. Any advice would be greatly appreciated. Thanks!
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