Melissa Koch, a Wake County mother with a chronic joint disorder, got authorization from her insurance company before ankle replacement surgery. When she got a letter after the procedure denying coverage, she reached out to 5 On Your Side.

A massive medical bill was wiped away after a Wake County woman reached out to WRAL 5 On Your Side.

Melissa Koch of Wendell has a chronic joint disorder that makes it hard to move around and care for her three young kids.

"All of my joints are affected by this," Koch explained to 5 On Your Side. "There's really no cartilage in any of my joints, and the little cartilage that is there is just wearing down over time, which is leading to needing the joint replacements."

To improve her mobility and relieve pain, Koch went in for her second ankle replacement surgery at Duke University Hospital in October 2024. Before the surgery, she got authorization from her insurance company, Blue Cross and Blue Shield of North Carolina, and didn't expect to pay anything out of pocket.

"We thought it was completely covered. Went through the surgery, October 24, completely fine. About a month later, Nov. 21, I got a letter in the mail that said, 'Sorry, we decided to deny the surgery,'" Koch said.

Koch appealed the decision but was denied again.

The denial said, "The services were denied as investigational." The claim amount on the denial was $126,035.12

WRAL 5 On Your Side asked if there was a moment where Koch thought she was going to have to pay that amount.

"Yeah, [after] the second denial, because most times after that, I didn't think that they would consider anything else I had to say. So that's why I called WRAL," Koch said.

WRAL 5 On Your Side reviewed Koch's records. The denial explained that the prosthetic ankle implant was 3D-printed, and it was considered experimental because BCBSNC did "not have enough scientific proof that this type of device is likely to benefit" Koch's quality of life.

BCBSNC reached this conclusion despite knowing Koch had the exact same procedure, with the same implant, at the same hospital, with the same doctor, four years earlier and she said it was successful.

Our team reached out to Duke University Hospital and Blue Cross and Blue Shield of North Carolina, asking them to look at Koch's case and whether the denial was appropriate.

A couple of weeks later, Koch got a letter in the mail from BCBSNC saying the denial for the $126,035.12 claim was being overturned.

"It was such a relief to finally be like, 'Okay, we're not in debt $126,000,'" Koch said.

Blue Cross and Blue Shield of North Carolina sent 5 On Your Side this statement shortly after:

"Blue Cross and Blue Shield of North Carolina is grateful for the opportunity to serve as Mrs. Koch's insurance plan and for her allowing us the chance to resolve this issue. We agree this should not have happened, and we apologize the member was put in the middle. As outlined in Mrs. Koch's explanation of benefits, the member should not have been held responsible for any out-of-pocket costs for the surgery or the implant.""

Duke University Health System CFO Lisa Goodlett told us there was a 3D-printed model used during Koch's care, but it wasn't part of the prosthetic.

"Duke had developed a model, a 3D model, to make sure that the implant would work as expected. It was never put in the patient, but somehow there was a thought that we had 3D material in the patient, which we didn't have," Goodlett explained.

During our interview, Goodlett said health insurance denials have become a "phenomenal problem" across the board.

"We have a team of over 150 people that just deal with denials from the various payors," Goodlett said. "98% of the time we get a denial, through this extra work we are able to get it overturned. So, why do we have to go through this 98%? Why don't we just get the patient paid, get it taken care of the first time?"

A recent study by KFF looked at 392 million in-network claims from 2023, and found that insurers denied 19% of those claims.

Less than 1% of denials were appealed by the consumer. When denials were appealed, insurers upheld 56% of those denials.

However, that's not the whole picture. Most insurer denial data is not public so it's hard to put any kind of context on the figures we do know.

Koch is hoping that by sharing what she went through, others will be inspired to fight these health insurance denials.

"I knew that this was wrong. If they know that, or if they believe theirs is wrong as well, that they can use their voice," Koch said.

Health insurance and billing can be confusing so 5 On Your Side continued discussions with Duke University Hospital and Blue Cross and Blue Shield of North Carolina after Koch's coverage denial was overturned.

During discussions, BCBSNC said the letter Koch got denying her appeal and noting the claim amount was $126,035.12, was not a bill. A spokesperson explained the letter did not ask for payment. However, the letter also did not say who was responsible for the claim amount.

A Blue Cross and Blue Shield of North Carolina spokesperson said this was a misunderstanding.