Hospitalized After Cosmetic Surgery?

Why This Health Insurance Appeal Failed — and What You Can Learn

Many people are shocked to learn that health insurance can deny hospital bills even when the care was serious, lengthy, and medically necessary.

That’s exactly what happened in a recent Florida case involving a woman who was hospitalized for more than a month after developing a severe infection following cosmetic surgery.

She appealed. She sued. She argued the care was an emergency. And she still lost.

This case, Reyes v. Blue Cross Blue Shield of Florida / Florida Keys Aqueduct Authority (2025), is an important warning for consumers — and a valuable lesson in what does not work in a health insurance appeal.

What Happened in This Case

The Surgery

• The patient underwent elective cosmetic surgery (liposuction and a tummy tuck).

• Her health insurance plan explicitly excluded cosmetic surgery.

• She agreed the surgery itself was not covered.

The Complications

• About 12 days later, she developed a serious infection at the surgical site.

• She was hospitalized for over a month.

• The care was expensive and medically intensive.

The Insurance Denial

• The insurer denied coverage.

• Reason given: The hospitalization was a complication of a non-covered cosmetic procedure.

The Appeal and Lawsuit

• The patient argued:

  • The hospitalization was not “cosmetic”

  • The care was an emergency

  • Federal law requires coverage for emergency services

The courts rejected all of these arguments.

Why the Insurance Company Won

The court focused on one critical issue:

What caused the hospitalization?

The medical records showed:

• The infection was at the cosmetic surgery incision site

• The hospitalization was directly linked to the surgery

Because the cause of the treatment was a non-covered service, the insurer was allowed to deny the claim — even though the treatment itself was serious and medically necessary.

Appeal Arguments That Failed — and Why

This is the most important part for consumers who want to appeal a denial.

Below are the exact arguments that failed in this case, with explanations you can learn from.

❌ Argument #1: “The Hospital Care Was Medically Necessary”

Why it failed: Medical necessity alone does not override a policy exclusion.

Insurance plans can legally say:

• “We don’t cover this type of surgery”

• “We also don’t cover complications arising from it”

Even though the patient genuinely needed treatment, the court said:

Medical necessity does not create coverage where the plan clearly excludes it.

Appeal lesson: You must challenge the policy exclusion itself, not just argue that the care was necessary.

❌ Argument #2: “This Was Emergency Medical Care”

Why it failed: The plan involved was a self-funded governmental health plan, which is exempt from Affordable Care Act emergency coverage rules.

That means:

• Federal “emergency services must be covered” rules did not apply

• The insurer was allowed to rely on its exclusions

Appeal lesson: Before arguing “emergency services,” you must determine:

• Is the plan fully insured or self-funded?

• Is it a governmental plan?

Emergency-care arguments do not work against all plans.

❌ Argument #3: “The Complications Were Separate From the Surgery”

Why it failed: The medical records clearly documented that:

• The infection arose from the surgical incision

• The hospitalization stemmed from post-operative complications

The patient submitted a doctor’s affidavit, but:

• It did not point to admissible evidence

• It did not contradict the medical records

Appeal lesson: Courts and insurers rely heavily on medical documentation, not opinions or conclusions.

To win this argument, you need:

• Independent medical evidence

• Clear documentation separating the complication from the excluded procedure

❌ Argument #4: “The Insurance Company Acted Unfairly”

Why it failed: The court found the insurer:

• Followed the plan language

• Applied the exclusion as written

• Relied on undisputed medical records

Bad outcomes do not equal bad faith.

Appeal lesson: Unfairness alone is not enough. Appeals must be tied to specific plan violations.

What Could Have Helped This Appeal?

While the patient lost, this case shows what might have changed the outcome:

• Evidence that the infection was unrelated to the cosmetic procedure

• Medical records showing a new, independent condition

• Proof the plan language was ambiguous

• Evidence the plan was misclassified (not truly self-funded)

Key Takeaways for Your Own Appeal

If your health insurance denied a claim for complications after a non-covered procedure:

✔ Always read the exclusion language carefully
✔ Focus on causation, not just severity
✔ Identify whether your plan is self-funded or fully insured
✔ Use medical records, not just statements
✔ Tailor your appeal to the exact reason code

Generic appeals fail. Targeted appeals win.

How AppealTemplates.com Helps You Avoid These Mistakes

Many people lose appeals because they:

• Use emotional arguments instead of legal ones

• Don’t address the actual exclusion

• Don’t know which arguments apply to their plan type

AppealTemplates.com provides attorney-written appeal templates that:

• Address exclusions directly

• Target the insurer’s stated denial reason

• Help you structure evidence correctly

• Avoid arguments courts consistently reject

Need Help Appealing a Denied Health Insurance Claim?

If your claim was denied due to:

• Cosmetic surgery exclusions

• “Complications of non-covered services”

• Emergency care denials

• Self-funded employer plans

Explore our appeal templates or download our FREE APPEAL GUIDE to avoid the mistakes that caused this appeal to fail.