Denials Queue
Medibank Private — Claims Assessment
Re: Northern Orthopaedic Day Surgery, Epping
Claim declined — Knee arthroscopy — J. Whitfield
Bupa — Hospital Pre-Approvals
Re: Spinal imaging request
Pre-approval declined — MRI lumbar spine
HCF — Prostheses Benefits
Re: Cataract day procedure
Claim short-paid — IOL prosthesis gap
From: Medibank Private <assessments@medibank.com.au>
Claim declined — MBK-88241
Dear Provider,
We have assessed claim MBK-88241 for member J. Whitfield (membership 6049 2231, Gold Hospital). The claimed service — knee arthroscopy, MBS item 49557, date of service 26 February 2026 — has been declined.
Our records indicate the condition is pre-existing. A 12-month waiting period applies and had not been served at the date of admission (clause 7.3, Pre-Existing Ailment).
You may lodge an appeal with supporting clinical evidence within 30 days of this notice.
Medibank Private — Claims Assessment
Extracted Case Facts
Patient
James Whitfield (DOB 14/06/1979)
denial notice
Membership
Medibank 6049 2231 — Gold Hospital
denial notice
Claim ref
MBK-88241
denial notice
Procedure
Knee arthroscopy — MBS item 49557
denial notice
Service date
26 February 2026, Northern Orthopaedic Day Surgery
op report
Denial reason
Pre-existing ailment — 12-mth wait unmet (clause 7.3)
denial notice
Clinical finding
Acute lateral meniscal tear — ski injury 12 Feb 2026
op report
Referral
GP referral 14 Feb 2026 — no prior knee symptoms noted
GP referral
Claims Hx
No knee-related claims in 36-month history
practice records
Appeal grounds
Acute onset post-membership — not pre-existing under PEA rule
AI assessment
Evidence-match confidence
Draft Appeal
Benefit value under appeal — drafted for clinician review, not auto-lodged.
Hospital accommodation
$1,840
Theatre & recovery
$2,150
Prosthesis & consumables
$640
Specialist gap (49557)
$420
Benefit under appeal
$5,050
Upheld on similar PEA appeals: 88%
Insurer response: within 20 business days
PEA rule turns on the certified symptom-onset date — treating surgeon's signed certificate not yet attached. Required before lodging.