How do you appeal when your health insurance doesn't want to cover a needed procedure?

Question

Is it necessary to hire an attorney?

Please help

Answer 1

No, its not necessary to hire an attorney. (At least, not for any of the early levels of appeal.)

Your certificate of coverage/policy document should specify appeal procedures - if not, you can get the appeals address from your insurance company. I don't know what state you're in, but generally the state Department of Insurance has guidelines as to appeal processes. You need to exhaust all levels of appeal with your insurer before the Dept of Insurance would be able to investigate on your behalf.

One question - is the service being denied because the insurer says that its not medically necessary? Or is the service being denied because its something that's an exclusion on your policy? If the service is spelled out as an exclusion, then there's not much you can do about it. Your policy is a contract, and the insurance company isn't obligated to cover anything that's excluded from your contract.

However, if its being denied stating that its not medically necessary, then your appeals need to demonstrate why the procedure IS medically necessary. Any and all documentation you have should be sent - chart notes from your physician or other health providers, etc. - send this documentation along with your letter of appeal.

Answer 2

Your plan has a specific appeals procedure. If you have a benefit handbook, consult it to see what the procedure is. If you don't have a handbook, contact the insurance company directly, or go to your Human Resources Department (if your insurance is through your employer) and ask for a handbook and information about the appeals procedure.

Typically, the appeals procedure is pretty cut and dried. If you need to have a medically necessary procedure that is a covered benefit under your insurance plan, it should be covered. Perhaps they are saying they won't cover it because they have not received sufficient information to make that determination. If the procedure is considered experimental, or elective, or not medically necessary, it won't be covered by your insurance . Your benefit handbook should have a list of specifically excluded procedures - if yours is on that list, it's not going to be covered even if you retain the services of an attorney.

Answer 3

No, you just get the declination letter from the health insurance company, and assemble the "evidence" countering the reason for the appeal.

Example: They say that open heart surgery isn't necessary. You submit letters from two different heart surgeons that say you need it.

Example: They say that the procedure is experimental. You submit letters from two different doctors saying it's routine, and an article from the new england journal of medicine.

The only time you're going to have a hard time appealing, is if the procedure is flat out not covered - Example: lap band surgery, cosmetic surgery, or infertility treatments. These are all considered VOLUNTARY, and not medically necessary.

Answer 4

It depends on why you're appealing? Did they state the service isn't medically necessary? Or, a non-covered service. Write a letter. Ask you doctor's office to help, & provide you with copies of your medical records. Mail it in to you insurance company, explaining why they should make an exception. Then, just wait...

Answer 5

Most states have a governing body for health insurance companies. Check your States website and you should be able to find out which one to contact.

Answer 6

1. You could call them and ask.
2. Your doctor may have seen this situation before.
3. There may be a website for people in your situation.