7 On Your Side helps family with six-figure medical bill after insurance denied coverage

MILLBURN (WABC) -- A late-game decision by a health insurance company became a serious pain in the neck for a Millburn, New Jersey, mom after a surgery she thought was covered landed her a six-figure bill.

After multiple appeals failed, she sent a lifeline to Nina Pineda and the 7 On Your Side team.

A ruptured disc in Ellen Gentile's neck was minutes away from being repaired when her surgery came to a screeching stop.

"There's been a terrible mistake. We're going to have to reschedule," as Ellen's husband Matthew Gentile, echoed the doctor's words.

The scheduled operation they believed was pre-approved was not authorized by their health insurance.

"The night before they called me and told me, come on in," Ellen said. "You know, we assumed everything was approved."

The pain was excruciating, but Ellen thought relief was moments away.

She was prepped and ready for surgery, with a gown on and hooked to an IV.

"There's no time left to reschedule. Look at her, the poor girl is in so much pain," Matthew said.

Despite the cancellation, they went ahead with the operation that day, since Ellen, who restores antiques, had been partially paralyzed unable to move her arms and hands.

"Did anyone tell you there that there's a chance it might not be covered at the at the surgery center?" Pineda asked.

"Well, the business director said this usually gets worked out," Matthew said.

A week later they got a letter from Independence -- her coverage was denied.

"And you're on the hook for how much?" Pineda asked.

"$110,000," Ellen said.

And that was before all the other charges: an artificial spine device $37,000; anesthesia almost $9,000; the grand total for surgery related costs: over $126,000.

"I mean, we kind of got to a point where we had two appeals. They were both denied," Matthew said. "We're like, where else? Where else do we turn? What else can we possibly do?"

7 On Your Side contacted Independence Blue Cross, submitting letters of medical necessity from Gentile's doctor; however, it denied the claim.

Because a device was not FDA approved, the surgery was not authorized, but there was still hope because this opened the opportunity for an external appeal through an independent third party.

In a statement to Eyewitness News from Independence Blue Cross, their spokesperson said, "At Independence Blue Cross (IBX) we understand that health care decisions are deeply personal and challenging. However, it is crucial that our members receive safe and effective care, consistent with the highest standards in the medical field. Our policies and decisions are guided by evidence-based practices and regulatory compliance to ensure the safety and well-being of our members. The U.S. Food and Drug Administration (FDA) has not approved the device proposed to be used as part of the procedure for the specific circumstances presented in this case. It is important to note that insurance coverage for this procedure was not approved prior to the surgery. Because the device is not FDA approved for the clinical circumstances, coverage for the surgery was not authorized. During the appeal, a second review of the facts upheld the coverage decision. The member can choose to appeal this decision to an independent third party. If she chooses to go forward with an external appeal, we will provide support and coordination throughout the process."

Gentile was grateful to 7 On Your Side.

"I mean, you were able to give us an avenue to pursue this an avenue to pursue this that was more favorable, and it was approved," Matthew said.

The appeal worked, and their denial was overturned!

$126,680.25 was covered.

"Thank you, thank you, thank you. We just can't thank you enough," Ellen said.

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