How do you write an appeal for a rejected medical procedure to the insurance company?

Question

2 doctors have recommended I have a medical procedure, and after and exhaustive amount of faxing and conferences, the insurance company rejected it again. I was told I have to go through the normal appeal procedure, but no one can tell me what that is. Can anyone help?

Answer 1

Depends on why they're denying it.... Is your insurance company stating the procedure isn't medically necessary? Or not covered? Experimental? I processed appeals @ an insurance company, and the amount of control your employer usually has is surprising.

If its not a covered benefit, and your insurance is funded by your employer, its probably not going to be approved the first time. The 2nd or 3rd level are usually more carefully reviewed. If your employer benefit plan doesn't cover something, its not covered... They usually don't overturn it, unless they have a REALLY good reason to.... i.e., life or death.

If they're stating its not medically necessary, you need to find out what criteria you are lacking, and get it done.

P.S. if its bariatric surgery, and you don't already meet all criteria listed on your plan, its pretty worthless to appeal before you do whatever you need to do to qualify.


Your letter should be short & sweet; the entire appeal should include ALL documentation you have including medical records, and dates of phone calls made, etc... Your letter should simply state you wish to appeal the decision to deny "whatever the procedure is" . Then list the reasons you feel a reconsideration is warranted. Address all issues/reasons you feel the decision should be over-turned. Try to address the rationale they used in their denial to you. Provide your insurance ID #, and contact info, via phone & mail. good luck.

Answer 2

Mbrcatz is absolutely correct.

I'll also add that your state will have an office that handles complaints like this from people who have managed care plans. (In Virginia, it's called the Ombudsman for Managed Care and it's part of the Bureau of Insurance.) They are not necessarily going to be able to help you with the appeal (though they should be able to give you some documentation about how the appeal process should work); nonetheless, documenting that you've spoken with this office is one good way to put pressure on the insurance company. They don't like to have the state investigating and they most particularly don't want to be booted out of the state as a result of too many complaints regarding the same issue.

The fact is, some insurance companies reject these things as a matter of course, knowing that a lot of people simply don't have the stamina to fight the battle. Sadly, they're right. Don't be one of them.

Answer 3

An attorney is just going to cost you $250 an hour for something you can do yourself. Don't waste your money.

When the insurance company rejected it, they did so for a reason.

You write them a letter, stating that you're appealing their decision. The REASON for the appeal is going to depend on why they rejected it. Not necessariy? Well, you have statements enclosed from two different doctors that it is (enclose copies). Experimental? Well, you have statements from two doctors, and XYZ reference from the internet, that shows this is the normal treatment for that specific problem.

You just have to tailor it, and refute their denial. It's not uncommon to have it rejected the first time - it doesn't go to a thinking review person until it comes in the SECOND time.

Answer 4

Call member services at your insurance company, ask them for the member appeals address and fax number, and if there's a specific person who handles them.

Write a letter to this person or department, explaining WHY the procedure is necessary - ask the 2 doctors to send a similar letter to provider appeals. Insurance companies are kind of stupid, you need to spell it out for them as simply as possibly why it's a benefit for you to have this procedure. (Meaning, will you save them big bucks in future treatment if you have this a preventative?) Keep a copy of this letter, and mail it with delivery confirmation.

Call and follow up 1 week after the letter has been delivered to check the status of your appeal, and ask when you can expect a response. (Many are within 30 days.)

Good luck!

Answer 5

Check this site for tips and advise:
General Letter for Insurance Appeals http://www.incontinet.com/articles/art_urin/geninslt.htm

Answer 6

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Answer 7

You'll drive yourself crazy trying to deal with the Insurance, they are in business to keep your money not give it back to you when it's necessary, so that is when a lawyer (hard nosed if you can find one) comes in handy.

Insurance co.s don't like dealing with lawyers but results are achieved much quicker that way and the chance of getting what you need will be a more possible outcome.

Good luck

Answer 8

You'll have to do it quickly before you die.

Answer 9

get an attourney