Lawyer who handles health insurance appeals. This is just intended as a general guide to what I generally do with appeals like this, and you should consult with an experienced lawyer in your jurisdiction, as everyone’s situation is different.
I generally advise my client NOT to immediately file an appeal, as the denial letter itself does not give enough information for you to file an effective appeal. You are likely to have 60 days from the date of the denial to file the appeal. Rather than file an immediate appeal, I generally do the following:
– Request a copy of the claim file. They are required to send it to you. It will have a much more complete basis for the decision than just the denial letter alone. Follow up by phone with the request a couple of days after you send it in, and keep following up until they send you the claim file.
– Ask for a copy of the medical necessity protocol that they applied, which they are also required to give you.
In the appeal letter, you should primarily argue how you satisfy the medical necessity criteria in the protocol, and why the facts the insurance company relied on in deciding lack of medical necessity are wrong. Have your doctor provide a statement explicitly addressing how you satisfy the criteria for medical necessity. A general letter from the doctor saying he or she thinks it is medically necessary is not enough.
Unfortunately, fairness arguments that they screwed up and you did everything you could don’t go very far with the insurance company or the courts.
If you are still denied after the appeal, it is likely you have the right to request an external review of the medical necessity determination. These programs are usually administered through your state insurance department. You generally have to file them with 120 days of receiving the final denial of your appeal.
Disclaimer: This content does not necessarily represent the views of IWB.