Although transplants may be covered, approval is far from automatic. I have read of lawsuits where insurance companies denied this procedure. Although transplants may be covered, approval is far from automatic. Insurance plans, especially under managed care, prefer to deny expensive procedures if they can find a legitimate reason. Even where a policy indicates that coverage exists, there are two clauses in most policies that can take you by surprise.
Interpretation is, again, up to the insurance plan's own claims department and medical staff.
In other words, even though your doctor is the one actually seeing and treating you, he or she needs to defend the treatment to the plan. With a traditional health insurance plan or a preferred provider plan, you need to deal directly with your insurance carrier. You can begin by asking the claims department for a written interpretation of their policy with regard to your condition. You and your doctor may want to supply the background information on your case to help them render a decision. In either case, a review committee makes a recommendation to the carrier for consideration and payment.