Kaiser Permanente · New Mexico
Denied on Breast reconstruction with free flap in New Mexico by Kaiser Permanente?The denial, the code, and the path to recovery.
Kaiser Permanente paid your out of network Breast reconstruction with free flap in New Mexico below the billed charge, or denied it outright. That gap is what federal independent dispute resolution exists to recover, and we prepare the submission for you.
CPT 19364 covers breast reconstruction using a free tissue flap with microvascular repair.
Why claims like this get denied.
Out of network Breast reconstruction with free flap claims in New Mexico are commonly underpaid or denied for reasons like these.
Denied as not medically necessary
The claim was denied as not medically necessary, common on plastic and reconstructive surgery procedures where the payer second guesses the indication.
Low out of network allowed amount
The claim was paid at a low out of network allowed amount, far under the billed charge.
Anchored to the qualifying payment amount
The payer priced the claim off the qualifying payment amount, which often sits well below the real market rate for Breast reconstruction with free flap.
Bundled into another code
The Breast reconstruction with free flap line was bundled into another code, so part of the work was never separately paid.
Modifier or documentation gap
A modifier or documentation gap let the payer downcode or deny rather than pay the level billed.
We do this for you.
When an out of network surgical claim is filed right, federal IDR routinely pays well above the insurer's first number, and most properly filed disputes go the provider's way. We build the submission, your billing team approves it, and you keep the recovery. We do this every day and we win most of the time. No one can promise a specific result on a specific claim, and we will not pretend otherwise.
No outcome is guaranteed. Results vary by claim, payer, specialty, and documentation. Any general figures reflect the published federal record across all disputes, not a prediction about your claim. This is general information, not legal or financial advice.
The window does not wait.
Most practices never file, and the window does not wait. After open negotiation ends you have four business days to start a dispute. Miss it and that money is gone for good. This is the part that costs surgical practices the most, doing nothing.
The pathway in New Mexico.
In New Mexico, the pathway for out of network surgical disputes is federal IDR for self funded plans and a state process for many fully insured plans. Self funded ERISA plans follow the federal IDR process while many fully insured plans follow a state pathway, so the plan type decides which process a dispute routes to.
- New Mexico references FAIR Health benchmarks in its state process for fully insured plans.
Send us this denial.
Send us this denial. We will tell you fast whether it qualifies and, if it does, we build the submission.
Common questions.
Was your Breast reconstruction with free flap claim underpaid by Kaiser Permanente in New Mexico?
If Kaiser Permanente paid your out of network Breast reconstruction with free flap in New Mexico below the billed charge, that gap is what federal IDR exists to recover. Send us the denial and we will tell you fast whether it qualifies.
Does federal IDR apply to Breast reconstruction with free flap in New Mexico?
In New Mexico, out of network surgical disputes route through federal IDR for self funded plans and a state process for many fully insured plans. Self funded ERISA plans follow the federal IDR process while many fully insured plans follow a state pathway, so the plan type decides which process a dispute routes to.
How does Sydra dispute a Kaiser Permanente denial on Breast reconstruction with free flap?
We build the federal IDR submission, your billing team approves it, and you keep the recovery. We do this every day and we win most of the time. No outcome is guaranteed, and we will not predict a result on a specific claim.