When Jodie Mazza contacted the Health Justice Clinic, her family was facing an unexpected setback in her husband Carl’s recovery from oral cancer. After undergoing treatment that required the removal of part of the roof of his mouth, Carl had been scheduled for a reconstructive surgery at Mayo Clinic, a procedure that would help restore function and improve his quality of life. The family’s health insurer had approved the surgery, and Jodie and Carl began the trip to Minnesota for the procedure.
While they were already on the road, however, they received terrible news: the insurer had withdrawn its approval.
The issue was not whether the surgery was medically necessary. Instead, the insurer objected to the billing code used by the surgeon. Because the procedure was rare and no existing CPT code accurately encompassed it, the Mayo Clinic submitted the claim using an unlisted code, consistent with medical coding guidance. The insurer treated the matter as a coding issue rather than a denial of coverage, leaving the Mazzas without access to the denial appeals process.
Complicating matters further, the family’s health plan was self-funded through Carl’s employer, placing it outside the authority of the Wisconsin Office of the Commissioner of Insurance. With traditional avenues unavailable, Jodie turned to the Health Justice Clinic for help.
“What stood out to me was that the surgery had already been approved, and the family was left with no clear path to appeal,” Michael Krispinsky said. “Our goal was simply to make sure they could access a covered procedure that was critical to Carl’s recovery.”
Michael, a Health Justice Clinic student studying to be a lawyer and a policymaker, reviewed the family’s health plan and discovered that the reconstructive surgery was explicitly covered under its terms. He also obtained documentation from the Mayo Clinic explaining why an unlisted code had been used and confirming that no existing CPT code accurately reflected the procedure. Together, these materials demonstrated that the surgery was covered, and the coding was appropriate.
Michael then brought the matter directly to the employer’s human resources department, urging it to either intervene with the insurer or issue a formal denial that could be appealed. After reviewing the information, HR worked with the insurer to reconsider the decision.
As a result, the insurer agreed to cover the surgery. The outcome spared the Mazza family approximately $60,000 in potential out-of-pocket costs and, most importantly, ensured Carl could receive the reconstructive care he needed. For Jodie and her family, the decision removed a significant financial and emotional burden during an already difficult chapter of their lives. This case demonstrates the value of having an advocate to help patients navigate complex insurance barriers and secure access to critical medical care when it matters most. ●