How Do I Know If a Procedure Is Covered by Insurance?

If you're considering private surgery, one of the first questions you should ask isn’t about the surgeon’s credentials or the hospital’s reputation-it’s whether your insurance will pay for it. Too many people assume their plan covers common procedures, only to get hit with a bill for thousands of dollars after the fact. The truth is, knowing if a procedure is covered isn’t as simple as checking a website or calling customer service once. It takes digging into your policy, asking the right questions, and sometimes fighting for clarity.

Start with your insurance policy documents

Your insurance plan doesn’t cover everything. Even if you’ve had the same plan for years, coverage can change yearly. The summary of benefits and coverage (SBC) document your insurer sent you at enrollment is the starting point. Look for sections labeled "Covered Services," "Exclusions," or "Prior Authorization Requirements." If you don’t have a physical copy, log into your insurer’s member portal and download the latest version. Don’t rely on what you remember from last year.

For example, if you’re planning a knee replacement, check if "orthopedic surgical procedures" are listed as covered. Then look for any fine print: "coverage limited to medically necessary procedures" or "requires pre-approval from a network provider." Many plans exclude elective or cosmetic surgeries-even if they’re painful or affect your mobility. A hip replacement for severe arthritis? Usually covered. A hip resurfacing for aesthetic reasons? Almost never.

Not all procedures are created equal

The same surgery can be covered or denied based on why you need it. Insurance companies use medical necessity guidelines to decide. These aren’t always obvious. For instance, a spinal fusion might be covered if you have degenerative disc disease with nerve compression, but denied if your doctor says it’s to relieve "chronic back pain" without imaging evidence of structural damage.

Insurers often follow standards set by organizations like the National Institute for Health and Care Excellence (NICE) in the UK or the American Medical Association in the US. Ask your surgeon’s office if they’ve submitted a letter of medical necessity to your insurer. That’s a formal document explaining why the procedure is needed-not just desired. Without it, approval is unlikely.

Ask your surgeon’s office to verify coverage

Most reputable private clinics have a dedicated team that handles insurance pre-authorization. Don’t assume your doctor will do this automatically. Go to your first consultation and say: "Can you or your billing team contact my insurer to confirm coverage for this procedure before we schedule anything?" They’ve done this hundreds of times. They know which insurers require pre-approval for specific codes, which ones have waiting periods, and which ones deny claims for common reasons.

Insurers use CPT codes (Current Procedural Terminology) to track procedures. A knee arthroscopy for meniscus repair is CPT 29880. If your plan doesn’t cover that exact code, you’re on the hook. Your surgeon’s office should give you the exact code and confirm it’s in your plan’s list of covered services. Get that confirmation in writing via email.

Pre-authorization isn’t a guarantee

Just because you got pre-authorization doesn’t mean you’re fully covered. Pre-authorization means the insurer agrees to review the claim. It doesn’t guarantee payment. Many claims get denied after surgery because the insurer claims the procedure was "more extensive than approved" or "performed by an out-of-network provider."

Always ask: "Is the hospital in-network? Is the anesthesiologist in-network? Is the surgical assistant in-network?" All three can bill you separately. A single surgery can involve five different providers. If even one is out-of-network, you could owe thousands. Ask your insurer for a list of in-network providers for that specific procedure and cross-check with your surgeon’s team.

Know your out-of-pocket costs

Even if your procedure is covered, you’re still responsible for deductibles, co-pays, and coinsurance. A plan that says "80% coverage" doesn’t mean you pay 20% of the total cost-it means you pay 20% of what the insurer considers "allowed amount." That amount is often far below what the hospital charges.

For example, your surgeon bills $15,000 for a shoulder replacement. Your insurer’s allowed amount is $9,000. You have 20% coinsurance. You pay $1,800-not $3,000. But if you haven’t met your $3,000 deductible yet, you pay that first. So your total out-of-pocket could be $4,800. Always ask your insurer for an estimate of your total responsibility before scheduling.

Appeal if you’re denied

Denials happen. Often, they’re mistakes. Maybe your diagnosis code was entered wrong. Maybe your doctor didn’t submit enough imaging. You have the right to appeal. Most insurers have a 30- to 60-day window to file an internal appeal. Request a written denial letter. It should list the exact reason for denial and how to appeal.

Write a clear letter explaining why the procedure is medically necessary. Include your doctor’s notes, MRI results, and any evidence showing failed conservative treatments (like physical therapy or injections). Many people win appeals on the second try. The insurer doesn’t want to pay for a lawsuit more than they want to pay for surgery.

What if your insurance won’t cover it?

If your procedure is denied and you still need it, you have options. Some private hospitals offer payment plans or discounts for upfront payment. Others partner with medical financing companies like CareCredit or Alphaeon Credit, which let you pay over time with low or zero interest for 12 to 24 months.

Some insurers offer supplemental policies that cover out-of-pocket costs for covered procedures. Others have high-deductible plans paired with health savings accounts (HSAs). If you’re eligible, contribute to an HSA-money you put in is tax-free, grows tax-free, and can be used for surgery costs.

And don’t assume that if one insurer says no, they all will. If you’re shopping for a new plan, ask for a list of covered procedures before you enroll. Compare plans side by side. A slightly higher premium might save you $10,000 in unexpected bills later.

Keep records of everything

Save every email, every call log, every letter. Write down the name of the person you spoke with, the date, and what they said. If you get a verbal approval, ask for a confirmation email. If you’re denied, keep the denial letter. This isn’t bureaucracy-it’s your protection. In 60% of denied claims, the issue is fixable with proper documentation.

When in doubt, ask for a second opinion

If your insurer denies coverage and your doctor says it’s necessary, get a second medical opinion. Many insurers require it before approving contested procedures. A second doctor’s note can change everything. It also gives you leverage if you appeal. Insurance companies don’t like being told they’re overruling two qualified physicians.

Remember: you’re not asking for luxury. You’re asking for care that improves your quality of life-whether that’s walking without pain, sleeping through the night, or returning to work. Don’t let a confusing policy stop you from getting the treatment you need. Be persistent. Be prepared. And never assume anything is covered until you have it in writing.