How can an Exclusion be appealed?

Roberta P

El Paso, TX
Best answers
I hope someone can give me incite on if a claim can be appealed.

Insurance has an exclusion clause "Joint replacement or other treatment of joints, spine, bones or connective tissue including tendons, ligaments and cartilage, unless related to a covered Injury."

Patient was at nail salon, getting nails done, bent down to get purse and had a sharp, excruciating pain. Lost control of my left leg and could not walk. Had to lean onto things and drag leg to move. Saw physician was diagnosed with sciatica, given a shot and given prescriptions for Prednisone and and Tramadol.

One week later, patient collapsed while walking, was admitted to the hospital so they could figure out what was wrong and to also manage pain, MRI found bulging discs.

Claims were denied due to no injury date, physician than reported date patient was seen in office as injury date, then claims have been denied for exclusion.

Is there a way to appeal this claim? Any help is greatly appreciated.
You probably need a documented cause of injury and apply the associated external cause code. It does not appear that there is a documented cause of injury other than perhaps strenuous movement.