How I finally appealed a denied insurance claim
Kate (now 21!) had dental surgery on 12/01/2025, a 4-5 hour procedure.
I don’t pay much attention to insurance stuff because it’s overwhelming. Before I joined my current company, it was also genuinely hard and expensive. Every day I’m grateful for my employer's coverage and, by extension, the generosity that makes it possible.
Kate has had 3–4 major dental surgeries over the last couple of years. She doesn’t technically qualify as “hillbilly” yet. Her dentist says that’s eight or fewer teeth. 😆
Kate also requires general anesthesia.
Dental surgery is not cheap, which means I know the exact limits of our dental coverage: $2,500 per year. Her most recent surgery came in just north of five figures. Thankfully, Kate has Medicaid as secondary insurance. Less thankfully, her dentist, who is excellent, no longer accepts Medicaid.
About a month later, another bill arrived. This one was for anesthesia. It was roughly half the cost of the surgery itself. Sigh.
I called the anesthesiologist’s office and learned they didn’t have Kate’s current insurance information. I gave it to them and asked them to resubmit the claim. They did. Denied. Denial code: 001.
This is classified as dental work, so medical does not cover anesthesia. I think. 001 isn’t super descriptive, it says:
We denied this service. Your benefits don't cover this kind of care. You can check your plan documents or go to the Benefits section of our website for a searchable list of what's covered.
Not super descriptive. AI (Gemini CLI) to the rescue. I downloaded the EOB and asked Gemini to scan it. It did and came back the above so I asked if it there were any other reasons possible?
While the document itself doesn't provide a specific medical rationale beyond the generic reason code 001 ("Your benefits don't cover this kind of care"), we can infer a highly likely explanation based on Kate's profile and typical insurance practices. Given that Kate's diagnosis is Developmentally Disabled, the most common scenario for an automatic denial like this is:
The Underlying Procedure was Dental: It is very common for special needs individuals to require general anesthesia for routine dental work that a neurotypical patient might do awake. Because routine dental care is generally excluded from medical plans, the automated claims system will automatically deny the associated anesthesia as "not covered care," even though the anesthesia itself is medically necessary due to her disability.
“Kate’s profile.” That’s a reference to other AI work I’ve been doing trying to make my life just a bit easier handling all the bureaucracy surrounding her (Guardianship, SSI, etc). My next prompt was, “How do I appeal?”
This is where it gets super fun and unexpected. With that other context, “Kate’s Profile,” Gemini’s first response was:
I will research Florida's specific legal requirements for anesthesia coverage for individuals with developmental disabilities and provide the exact steps to file the appeal with the insurance provider.
It came back with this:
✦ To appeal this denial, you need to challenge the automated determination that the care is "not covered." Because Kate has a developmental disability, Florida law likely requires them to cover the anesthesia and facility charges, even if the underlying procedure (like dental work) is not normally covered.
The Strategy: Use Florida Law
Florida law mandates that health insurance policies must cover general anesthesia and associated hospital/facility charges for dental procedures if the patient meets specific criteria. Since Kate is over age 8, your appeal will rely on:
Statute: Fla. Stat. § 627.65755
The Argument: Kate has a developmental disability (as noted in her profile.json) that creates a "significant or undue medical risk" if dental or minor medical treatment were performed without general anesthesia in a controlled environment.
This isn’t an example of AI “knowing the law.” It’s an example of AI making a path visible that was previously opaque enough to stop me from trying.
This is the second time in as many weeks that it has helped me overcome a bureaucratic hurdle that usually stops me from pursuing a thing. The last time, it helped me transfer Kate’s Conservator Payee (SSI) from my mom to myself. My mom handled it previously because I would not engage with that labyrinthine system. She’s retired. It took her 10 months. I’m ridiculously grateful and lucky.
If you’re looking for ways to utilize AI, here’s another.
*Editor's Note
I posted this internally a few weeks back. I'm slowing making my way back out into public waters.
