From http://www.vhi.org/ health_insurance_intro.asp
When preparing for surgery, nerves are likely already high. A health insurance denial only adds to the problem. Many people don’t learn until after their procedure that their procedure will not be covered by their medical insurance. In some situations – emergencies for example – it’s unavoidable. But when you have an opportunity to schedule a surgery in advance, it is best to ensure that your insurance company plans to cover the procedure as expected. Take the initiative to make a phone call and seek to speak with a supervisor. If you can find out that the insurance company will cover the procedure, ask for an email address so you can follow up with a confirmation email. Of course, it won’t always be so simple.
If you are told that the procedure isn’t covered – or if you know it falls outside of your insurance coverage (whether as a result of the procedure itself not being covered or if your preferred surgeon is out-of-network) – you may have a new part-time job on your hands. But if you are prepared to fight and you are persistent, you have a reasonable chance of getting your procedure covered.
When told that your procedure is not covered, begin by finding out exactly what procedure the insurance company is representing they do not cover. Asking simple questions from the start may bring to your attention that an easily rectifiable mistake was made. It’s possible, for example, that the doctor’s office entered the wrong CPT code. A CPT code is a number maintained by the American Medical Association that is assigned to each task and service a medical practitioner provides to a patient. Each surgical procedure has a unique CPT code and if the code was entered improperly, the insurance company may believe you are preparing for a surgery that isn’t necessary.
Get documentation. If a claim is denied, whether before or after the surgical procedure, request the denial letter so you can respond directly to the reasoning offered for the denial when you appeal the decision. You will also want your insurance plan’s benefits and policies. These are often available online. This will assist in your determination regarding what procedures may not be considered medically necessary or scientifically sound and why.
Perform research. With denial letter in hand, perform the research necessary to rebut the claims of the insurance company. One of the first situations I dealt with out of law school was helping to ensure coverage of a surgical procedure. Rather than performing legal research, I was researching a specific medical procedure and even specific surgeons so I could refute the claims involved in the denial letter. The denial letter stated that the insurance company’s clinical staff determined that they had specialists able to provide the same surgery within the insured’s geographic area. The situation called for research focusing on demonstrating that the surgeon outside of the geographic area was an expert in the field and that the surgeons within the area had very little experience performing the surgery. Additionally, the out-of-network surgeon performed a slightly different surgery that the insurance company would argue was not scientifically proven. There were a number of peer-reviewed publications which demonstrated plenty of data and science that backed up the value and superiority of the surgical procedure. Helpful sites for such research include pubmed.gov and Google Scholar.
Use facts. Consider any special circumstances and individual characteristics. Your individual circumstances, which may be demonstrated in part by your medical records, may bolster your case. Demonstrate that the surgery may be superior to another option for a number of reasons. For example, perhaps one surgical method is likely to cause less bleeding. If you are anemic, excess blood loss may be an issue that medical professionals would recommend that you avoid. Using your facts and circumstances in conjunction with your research will help present an overall picture more likely to persuade the insurance company.
Seek help from your doctor. Your appeal may be bolstered further by a letter submitted from your surgeon explaining why the surgery is a necessity.
Even if your appeal is denied – and even once you have exhausted all appeals allowed by the insurance company – nearly every state allows patients to have their appeals considered by an independent external medical review board.
Finally, you may consider engaging an attorney. In a 2007 CNN.com article, the writer explained that it was the threat of a lawsuit that ultimately seemed to help the insurance company make up its mind to cover $200,000 of disputed medical costs.
Other considerations include seeking an expedited appeals process when the appeal is occurring prior to an already scheduled procedure. The insurance company should provide details regarding how to appeal and when an appeal may be expedited. Additionally, keep records throughout. Any time you make a phone call, record who you spoke with and what you spoke about. You never know if the person on the other end is properly entering notes into the system to create a history of your process.
Given a bit of persistence, you may be able to successfully appeal your insurance carrier’s decision.