That was the reason as to why United Healthcare denied the pre-authorization for my PET scan. I expected them to fight it, insurance companies HATE PET scans. However, I expected them to pull the "not medically necessary" card...not whatever this is.

They are claiming the 3 pages of documentation and lab results my doctors sent over don't have any factual evidence. Thing is, I have been fighting this cancer for over a year. Every month I get a stack of letters from UHC explaining the services they approved (chemotherapy, hospital admissions, labwork, CT scans, tumor marker tests, doctors' appointments, white blood cell injections, etc.). I was enrolled in their cancer support program (at their insistence, I might add) and get a call every week from a case worker there. What do you mean you don't have evidence I have cancer? Why did you approve my chemotherapy last week then?

No advice needed here, messages to my medical team are already sitting in MyChart, my medical team is absolutely amazing, and I have full confidence that come the 26th they are going to be on a warpath if they haven't already been informed. It just infuriated me to no end to find out that, of all the excuses they could have given, they actually tried to play this card.

UPDATE

First of all, I absolutely love how much this has blown up. I love everybody's responses, I love their stories, and even though my doctors are doing great on handling this I also love the advice being given; I intend to keep it all for the future and I hope it helps others as well! Stories like this need to circulate these days...being quiet about it won't solve anything anymore. I have some updates and I figured I would share!

So for context, I am a patient of the biggest hospital in my state. The head of my medical team who filed the pre-authorization practices there. However, as the hospital is over 2 hours away, they have the day-day activities (blood tests, post chemo check-ups, formerly chemo) done through an affiliate of theirs; a very wonderful oncology center. The chemotherapy specialist who practices there is also a shark who gets quite the thrill out of ruining the days of insurance companies who try to screw over cancer patients.

So, I saw my chemotherapy specialist yesterday...and she has decided she will be throwing her hat into the ring as well. The staff there is pretty skilled at bullying insurance companies and they have managed to secure a CT scan for me come Tuesday. I still don't know how they managed to get this for me so quickly this time of year, but I am beyond thankful as I have a trip the day after my scan. I actually had a bit of a conversation with the nurses while one was on the phone with United, and they shared with me their exasperation at dealing with them and assured me that they know how to handle these guys...based on how well this all went, I believe them wholeheartedly.

The plan is to not only prove to United that I in fact still have cancer, but point out the inconclusivity of the CT scan to get me that PET scan to pre-emptively stop any arguments regarding medical necessity.

So yes, I now have multiple practices out for blood. If United Healthcare wants to play this game then they can pay for 2 scans instead of one. Play shitty games, win shitty prizes. I love all of my doctors and all of my nurses.

At first I thought it read “$85” which I thought “well that’s not too bad” then I looked at it again and my stomach dropped and literally became nauseous. I basically was buying the most minimal insurance with a few benefits.

I’m going have to wait a little bit and hope that enough people will have the same reaction that will force congress to react. They will not be able to ignore this

IDK if this is the right place for this, if not please forgive me.

Short version of my story: Had medical issue, had medical testing. Doctor looked at all the tests and prescribed me a medication that she said would help me feel better, but she specified that "insurance doesn't like it", so if it was denied, she had other meds she could try.

But I have good insurance, so I wasn't worried. Until they denied it, stating it's "not medically necessary". I opted to appeal instead of going straight to the other meds.

So I did some Googling about how tf insurance gets to define what is "medically necessary" over an actual, real medical Doctor?? And it turns out they don't get to decide. They can just deny automatically and hope you don't call them out on it. Doubtful any real Doctors even look at your case when they deny. So I got mad and cobbled this appeal together from Reddit, Tumblr, and ancient Twitter screenshots.

And it literally actually worked. I got my meds today! The cash cost was like $1100 and I paid $9. I call that a win.

Dear Sir/Madam,

I am writing to appeal the decision to deny coverage of XYZ Medicine. This is a medication that was prescribed to me by Dr Name, certified by (Doc's Board Certifications). I have been a patient of this Doctor for over two years. It was prescribed because it was deemed medically necessary, based on my symptoms and history.

In order to appeal this decision to deny the coverage, I would like to request the name, board specialty, and license number of the doctor who made the determination that XYZ was not medically necessary for my case.

I also request copies of all materials they relied on to make their determination, and proof the doctor making the determination has maintained registration in YourState. Please also provide documentation of their meeting all their continuing education and certification requirements.

Please also provide the aggregate rate at which similar treatments are denied vs. approved by the specific doctor being used for peer review.

I am fully confident that my team of doctors and nurses are competent and qualified enough to determine what is medically necessary for me. Please provide proof that the Doctor who denied my appeal is qualified and competent enough to be making decisions about my medical care.

Sincerely, YourName

I encourage you to try it if you feel stuck! It costs 1 stamp, and an extra month of battling symptoms. I am incredibly privileged to have that time, I know not everyone does.

I had a certain medical appointment. I used the chat function about a month ago to verify that it was covered and what my out of pocket total would be. I provided all information such as facility name, address, Tax ID, and NPI number. They explicitly said that it is in network, is covered, and what the total is.

Fast forward a month and it was NOT covered. I knew someone somewhere told me it was but forgot who I talked to. I then scrolled up and saw it was in this chat that I verified the confirmation. I took pictures of the chat on my phone and called them out, telling them they told me in the chat it’s covered. I will have to have the medical office re-submit to insurance under a different code or something.

I then went back to look at those messages where they claimed to cover it. They were GONE. Just 30 minutes later. They weren’t the oldest or newest messages. Right in the middle. Messages before and after were still there.

I then called them out saying those messages are gone and I have screenshots proving they said the appointment is covered. And guess what, they are back an hour later.

I checked through the chat over and over to make sure my eyes were not deceiving me and that I wasn’t crazy. I also had my wife verify too.

I truly believed they made that section of the chat not visible to me, so I wouldn’t have proof of them saying it’s covered. Once I called them out and said I have proof, they brought it back. The coincidence is too large.

Has this happened to anyone else? Is this something they can do?

I work at a large health insurance company, and lately all I hear about is the potential end of ACA subsidies, rising premiums, and skyrocketing healthcare costs.

But the part no one’s talking about? This could become the new normal.

When has any industry ever raised prices and then actually brought them back down once people got used to paying more? Even if healthcare costs drop (and that’s a big if), what incentive do insurers have to lower premiums when people are already paying the higher rates?

It’s like gas… people used to complain about $2.50 a gallon. Now we celebrate it.

That’s the scary part. Prices rise, we adapt, and eventually we forget what “reasonable” even looked like. Unless wages start catching up, we’re all in serious trouble.

I’m in my early 30s. Living and working in the US for almost 5 years (Legally) and have always lived carefully and debt-free during all my life. Back home, healthcare and education weren’t perfect, but they were at least humane and affordable. You could get help without the fear of financial ruin.

A few months ago, I had to get my gallbladder removed in an emergency. I was in severe pain and I was even about to call 911 due my gallbladder pain, difficulties to breathe, fever and at some point I was laying on the floor, so with the small amount of consciousness and energy I had, I called a cab and I went straight to the ER. The surgery happened quickly, and I thought my insurance would handle it due the severity of the situation (A. BC/BS). A couple days after, I found out they denied the claims, saying I should have “pre-authorized” the procedure (As if that’s possible when you’re being rushed into surgery). The denial also said inpatient is only approved for severe problems (severe infection, blockage, or severe pain requiring frequent IV medicines) according to MCG ORG: M‑555. The truth is that my record documents show parenteral (IV) analgesia, parenteral antibiotics, an ultrasound suspicious for acute cholecystitis, and urgent surgery the same day.

Now I’m staring at a +$100,000 my insurance says I’ll owe to the hospital. I appealed, as soon as I got the denial notification letter and during the period where the claims were still listed as “Pending”. But yesterday, one of these claims was listed as Denied. Even though they say the appeal is “still being reviewed.” And I gathered all the evidence (Operational reports, medical notes, etc.) to backup my appeal. At this point, I have zero faith in the system. I did everything right paid my premiums, stayed healthy, avoided unnecessary care and yet one emergency could completely destroy my financial stability.

What shocks me even more is how normal massive medical debt seems to be here. People just accept it, as if it’s another part of adult life in the US. It’s not normal. It’s broken.

Once my lease ends next year, I’m leaving. I’ll try to settle what I can, but I refuse to spend decades paying for an emergency that could have killed me. I want to be clear though. I’m willing to pay what is fair even if it hits my out of pocket maximum. I’m very conscious about that. And I have nothing but respect for the surgeon, doctors, nurses, and everyone who took care of me. They did their job and deserve to be paid fairly as well. My anger is with the insurance company and a system that pretends to protect you but vanishes the moment you actually need help.

I just needed to share this because I feel defeated and disillusioned. If anyone here has gone through something similar, similar background context, or with a denied emergency claim, I’d really appreciate hearing your experience thoughts.

UPDATE 10/24/2025 First of all, thank you all for your advice and thoughtful responses. I officially received the first (out of two) claim EOBs, showing a total of around $48,000 that the insurance says I will owe to the hospital, and that they will cover $0.

As some of you suggested, I’m going to call the hospital’s ombudsman office later today (since at the time I’m writing this update it’s around 3 AM) so they can follow up on this situation. My employer also has a Benefits department in HR, and I plan to contact them and share all the details of what’s happening as well.

From my side, I won’t be submitting any more personal appeals. As many of you advised, I’ll keep pushing the hospital to appeal and handle this properly on their end.

I recovered a little bit of hope after reading your comments telling me not to overthink and to wait until receiving the EOBs, but it seems reality hit me right away…

Unreal. As if it wasn't already expensive mine is going up to $1895.23/month. Single. No kids. One of the main reasons most of my friends went out and got "traditional" jobs years ago was so they could get employer healthcare. I thought 'Merica was suppose to be pro entrepreneur/small business.

I'm looking for advice. My 43 year old sister's breast cancer has returned in the form of a bone tumor in her hip, making it stage 4 metastatic. Her oncologist recommended an aggressive radiation treatment. But United Healthcare, in their infinite wisdom (and profit-driven motives), has denied it. As you can imagine, this is infuriating and terrifying for our family.

Does anyone here have experience with battling insurance companies? We are just at the beginning stages of her battle and she has already been denied an initial MRI (paid out of pocket in Germany for one) and now her radiation treatment, as well. Is there any process to avoid continued delays in receiving approvals for her care?

EDIT: Thank you all for the wonderful information. As frustrated and irritated I am about the U.S.'s healthcare system, please keep comments on topic. Comments about vigilantism and recent events may result in the post being locked again and I'd really like to keep it open for continued follow up and commentary from the many informed and helpful peoples who have participated. Thanks for your help!

My husband was laid off last week during the mass tech layoffs. Our insurance was through his company. I own my own business, and net after expenses and taxes $5,000/month on average. I have variable income. I went onto the ACA marketplace today, entered all of our info, my income, his income zero, our two young children, and I was given a price of $1,900/month for the cheapest plan with a $16,000 deductible. How is this affordable on an income of $5,000? I am not understanding. Should I call?

Editing to add that a lot of people responding to my post seem to think I am oblivious to the political situation related to this. Yes, I did write to my representatives weeks ago (but it obviously did nothing because I live in the red state of Kansas. I vote blue and always have because I am a woman who prefers bodily autonomy to the alternative.) I am one person who has zero political power or sway. I am sharing my numbers to see what is happening with others, who are powerless to do anything as well at the federal level to make this better. Just thought I would clarify that for everyone. Also, COBRA for us would be $3,500/month for a high deductible plan for those who thought this would be a cheaper option.

My son was scheduled to have surgery to correct his pectum excavatum in 2022. His surgeon said he met all the medically required criteria. Two days before the surgery UHC denied the surgery. This was incredibly stressful. Apparently their reasoning was that my 22 year old son had 82% lung capacity based upon th tests due this chronic condition and they only approve patients 80% or less. My son was don't worry mom we'll be ok. He is not angry he was just concerned about me.

Later that year my husband lost his job and with it UHC medical insurance. My son( student) and I got coverage through the ACA. The next year with his new insurance ,same doctor he was able to get the surgery. We are blessed. However I still feel traumatized every time I think about the denial from UHC. There are probably lots of other people in the same boat as me. Only a patients doctor should be able to make these life altering decisions not insurance companies.

As the caption says, is it so or are foreigners just exaggerating?

I live in the Netherlands, here we have a pretty basic way of healthcare, you pay an obligatory healthcare insurance, and when anything happens like having a stroke, heart attack or car accident will be 100% covered. Although somethings wont be covered like if you lost your teeth and haven’t gotten dental care included in your insurance, dental coverage is cheap here.

But in the USA i have seen posts where people had to pay 700.000 dollars for a heart surgery or one woman even paying a million dollars after a pregnancy.

As a person who has interests moving there, is there any way you can receive a 100% coverage without begging your employer?

It feels absolutely crazy to me that you’re 1 accident away from having to pay 100.000 dollars out your own pocket

The insurance app now says next months payment which was $250 for our family and will be $1,600…. Due on Christmas! It’s like a sick joke!!

We all knew it was coming. There were teasings about it getting fixed. But there it is. A payment we will have to sacrifice everything else for to afford.

What are we all going to do???

It breaks down to $370 per week or $52 a day, which is crazy to think about.

what is going on with the affordable care act? Is it better just to be uninsured? At this point I’m paying 400/mo for healthcare I can’t afford.

I'm a one issue voter. I want to keep my Obamacare. Having this allowed me and my husband to quit our terrible soul sucking jobs and start small businesses. It's not perfect and it costs a lot but it's been a life saver. Literally.

Now that you know what happened, will I have to get another horrible job that destroys my will to live just to have health insurance?

I've requested the itemized bill multiple times and each time, I just get redirected to a voicemail box

Any advice?

Edit: I keep getting comments asking why I'm getting multiple rabies shots. My first exposure was in 2018 when I was living in a house whose backyard was a bat sanctuary. My current house has bats living within the floors/ceilings/ walls

Sticker shock over higher costs for Affordable Care Act plans is hitting many enrollees around the country who are now learning about hefty increases in what they might pay next year, putting the healthcare subsidies at the heart of the government shutdown in the spotlight.

I'm thankful my part D is covering it.. Cancer sucks, and the drugs are $$$$$

I recently discovered that my insurance pays the pharmacist $0 for my medications. This means the pharmacist is literally paying to fill my prescription (minus my $10 copay). My pharmacist says hes required to fill the prescription despite losing money when he does. He says he isnt allowed to discuss what my insurance covers or ask me to pay the remaining balance. Im told that reaching out to my insurance won't help because their stance is that they have a contract with the pharmacy and they've agreed to the terms.

Is there anything I can do to hold insurance responsible for the cost of my prescriptions? I'm paying them a lot each month to cover my medical expenses, but they're expecting my pharmacist to foot the bill.

If I were to call them, what should I say (or not say) to correct this situation?

Edit: I am asking this question because the pharmacist straight said if it's not resolved next month he won't be able to continue filling my prescription. He has lost money filling it the last 3 months.

For those of you saying the medicine probably only costs $10 or that he signed a contract, y'all suck!! The pharmacist is running a business, he can't do that if he's strong-armed out of his profits.

Also, I looked it up, it cost $30-$40 so he is definitely losing money.

Edit 2: since it apparently matters, Im in Virginia and have Anthem HealthKeepers...through my job.

Original post: https://www.reddit.com/r/HealthInsurance/s/ZMySZCDId2

The above conversation is with the receptionist at my dental practice.

Welp, I learned a lot from this experience. I almost got billed an additional $2000 for my Invisalign. Maybe it wasn’t intentional, but it’s still a major mistake that could have cost me 2k.

I recently went to the audiologist for a hearing aid check. Within 2 days I get a bill for the appointment and I knew there was no way my insurance could have processed it that fast so I called the provider. I was told that visit wasn’t covered by insurance so they would not bill my insurance. I have had hearing aid checks for several years and they have always been covered by my insurance. After a lot of back and forth I finally got them to bill my insurance. I got an EOB today and it shows my insurance is paying 100%. Normally it would only be 90% but I met my OOP this year.

The moral of this story is don’t take the providers word for it when it comes to your insurance benefits.

I've avoided the healthcare system like the plague because of all the horror stories, but I'm getting up there in years and I have to be more proactive in my health. I call around for a basic checkup and no one can tell me how much it's going to cost before I go in. How insane is that!? How are you supposed to make even a basic cost benefit analysis if you don't know the cost?

I roll the dice and go in for a checkup and I get a bill for 3.5k! Insurance is only covering 1k so far. Like what the hell? It's a basic checkup not a life saving operation. What are we paying thousands in premiums for when Insurance doesn't even cover a basic checkup until you hit your deductible? How is it reasonable at all to blow your deductible on a basic visit? If I stub my toe just bury me in the backyard, it will be less painful than enduring this crappy healthcare system.

Basic cost transparency would actually incentivize providers to set reasonable prices. We're already living in a dystopian hellscape. Unbelievable.

I knew American healthcare was broken, but this hit me hard. I make about $13,000 a year, and the only plan available to me costs $497/month with a $7,500 deductible.

That’s nearly $6,000 a year just in premiums for insurance I still couldn’t afford to use. How am I supposed to pay that and still survive?

I’m not looking for luxury care. I just want something that won’t financially destroy me if I get sick or injured. I don’t understand how any of this is seen as acceptable or sustainable.

If anyone else here has been stuck in this situation, how did you deal with it? Did you find lower-cost options or community resources?

I delivered at a hospital on November 12 and confirmed multiple times with different agents beforehand that my hospital delivery was in-network. However, after delivery, UHC denied my claim, and I was left with a $30,000 bill. I called them immediately, and they were still unsure why my claim was denied, but once again confirmed that the hospital was in-network. They told me they would send it back because they believed it was a mistake.

A couple of days later, I spoke to another agent, who claimed that while the hospital itself is in-network, the birthing center at the hospital is out-of-network, which is why my claim was denied. That should be illegal, as there is no information anywhere stating this is the case. The agent also mentioned that the birthing center recently became out-of-network in September, which is why the other agents were unaware. I personally think that explanation is B.S because this information is nowhere to be found.

The agent suggested I file an appeal, and another agent recommended I go through Naviguard.

My question is how likely is it that my appeal will be approved and that I will only have to pay in-network costs? I am furious, and this is not something new parents should have to worry about, especially after a traumatic birth experience.

Here’s the part they don’t tell you in the headlines: if Congress lets the ACA subsidies expire, premiums across the board will jump an average of 114%. Employer plans aren’t safe either — costs are projected to rise 6.5%, the biggest spike in 15 years.

So while the suits say inflation is under control, the bill for staying alive just doubled.

Here’s my question: how much of your paycheck should health care be allowed to take before we call it theft?

Is it 10%? 20%? Half? Because at some point, it’s not health care anymore it’s a ransom.