The ER will admit you if you need immediate treatment, yes, but that does not mean your insurance will cover it.

Yes, you will be admitted and the procedure will be performed, but also as someone who has worked in your field, the procedure's paper work is submitted AFTER the surgery. Once there, if it isn't covered by your insurance, you will receive a bill that you will be responsible for because your insurance won't cover it.

You can appeal all day, every day, but that's not going to make a difference if your insurance won't cover it.

You can whine, cry, appeal, plead, moan **** and groan every day, all day long, but you will still be stuck with a bill. Sure, the procedure was performed, but someone has to still pay for the uninsured procedure, right? Right! 

If your insurance specifically does not pay for weight loss surgery or its complications, then you have to pay for your surgery and you have to pay for any complications of that surgery.

If I have a car accident and do not have comprehensive coverage, then I pay for my own car repairs.  If the repairs are not satisfactory and something breaks, then can I make the automobile insurance company pay for the subsequent repairs? 

Would they not laugh me out the door if I tried?

Does the insurance company that you work for pay for claims for procedures that are not covered by the insurance policy? 

Are you actually making the decision to pay people for medical procedures that are not covered, or are you simply processing claims that have already been approved by someone higher in the company.  Do you see any of the claims that are not approved?  Are you able to overturn claims that are not approved?

Wow...I am so surprised by the responses to my response lol.   I will explain it to you because you asked nicely.   Without rude.com chiming in, I will very simply explain what I meant by my statement.  I misread that she already had the procedure.  If you let's say... had a breast implant surgery.  During the surgery you flat line and are transferred from the surgeon to the hospital on an emergency basis, your insurance would absolutely cover the emergency care.  If you don't believe me google it.  If you don't believe that, call your insurance carrier.  

I actually work for a TPA.  My clients, very typically pay for what's necessary to cure or relieve the effects of an industrial injury. 

The decisions are made using criteria to accept the entire claim, or deny an entire claim.  This criteria includes applicable labor code.  There is a process called utilization review (non emergency services) which review medical procedures and determine if they are medically necessary.  

I'll give an example, let's say you are a 500 lb man.  You are at work and you hurt your back.  You are going to PT (accepted claim by my client).  And your doctor determines you need to lose weight in order for your back pain to lessen.  As an insurance carrier, that is 100% covered.  Maybe not surgery, but definitely Lindora or the like.  I can cite case law if you would like.  

I see claims which are not approved all the time.  And sometimes legally speaking we are not in a sound position when it comes to litigation.  And yes, when a claim meets certain criteria a claim can go from being denied, to being approved. Work comp law is extremely complicated so I won't bore you with the details but yes definitely.  Maybe private insurance is different in some ways, but I do know certain things are the same.  

Third-party administrator

A Third Party Administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity.^[1] This can be viewed as "outsourcing" the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk. The risk of loss remains with the employer, and not with the TPA. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions. While some third-party administrators may operate as units of insurance companies, they are often independen

since  you deleted your  reply it is to show people what  A  TPA is ..... a  processor of claims,,,, is that not what you said you do???????????????????????////

Oh sorry.  I deleted my reply cuz it listed duplicatively

Hi dove :)

Third-party administrator

A Third Party Administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity.^[1] This can be viewed as "outsourcing" the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk. The risk of loss remains with the employer, and not with the TPA. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions. While some third-party administrators may operate as units of insurance companies, they are often independent.

I still think of the Applebee commercial, lady at desk stamps EVERYTHING approved :)

There's always more to learn in life.  Wise people listen and learn.

OP - I wish you luck in having your treatment covered.  As stated, the key is what is the reason for the denial.  The suggestion of getting a patient advocate or ombudsman at the hospital is probably a good idea.  The hospital wants the bill paid so I'm sure they'll assist you in trying to get the insurance carrier to pay.  If insurance doesn't cover it, then you should negotiate the bill.