Once her doctor recommended sinus surgery, and insurance confirmed prior authorization wasn't needed, Christine Knirk focused on getting the procedure and getting better.

The outpatient operation happened just over a year ago and has brought the medical relief Knirk sought.

But getting the procedure paid for by insurance has created months of aggravation for the 65-year-old Burnsville, Minnesota resident.

Knirk's story is a window into the continuing — and perhaps growing — tension between health insurers and health care providers over coverage denials. Denials without a clear reason can be maddening for patients who are often left feeling helpless. It also highlights the lack of comprehensive public data on how often and why denials happen.

"We've always been frustrated with the lack of transparency ... trying to figure out what are the types of services that are being denied and what are the reasons," said Kaye Pestaina, a vice president at the California-based health policy group KFF.

In August, Horizon Blue Cross Blue Shield of New Jersey — the insurer for Knirk's employer-sponsored health plan — told her after the procedure was done that it would not cover most surgery costs. The insurer had determined the procedure was not medically necessary.

Knirk began the appeal process the next month, but hit a low point in late March when she received a letter from her health care provider, Park Nicollet, relaying that she was responsible for more than $30,000.

Working on the appeal was confusing and plagued by miscommunication, Knirk said. She spent decades working in customer service, addressing concerns over the phone for a manufacturer, until her recent retirement. Her experience trying to get clear support from the health care companies was jarring.

"I come from the school of customer service where you take the call, you take the issue and you follow it through resolution," Knirk said. "Nobody seems to want to do that. ... I'm stuck in the middle."

In early April, the Star Tribune contacted both Horizon Blue Cross Blue Shield and Park Nicollet with questions about the billing dispute. Just over a week later, the insurer said it was paying the bill with no additional financial responsibility for Knirk.

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