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How to Write a Winning Insurance Appeal

Brittany Cheree Allen, Esq.

If you’re living with a chronic illness, chances are you’ve had to battle your insurance company for coverage of a treatment, medication, or procedure. This issue is a particular concern for home parenteral and/or enteral nutrition (HPEN) patients since many insurance policies try to exclude coverage for supplemental nutrition. The appeals process can be complex and seem daunting, but you can learn to effectively self-advocate and write a winning insurance appeal by making yourself familiar with the process and following our tips below.

Nationally, although 94 percent of insurance deni`als are never appealed, approximately 70 percent of health insurance appeals are granted. Insurers are counting on you giving up after receiving a denial, but making the effort to appeal can pay off. The following information should help you navigate the process and write a winning insurance appeal.

 

Notification of Denial

The first thing you need to do is determine the reason for the denial. There are a lot of ways an insurer can notify you of a denied claim. Your Explanation of Benefits, or “EOB,” can constitute a denial. If your EOB shows that payment was denied, there should be a reason code next to the treatment or procedure. You can find a definition of that code at the bottom of the page or on the back of the EOB. Insurance companies MUST provide the reason for the denial and explain your appeal options, sometimes called “grievances.”

A denial letter may also be sent, to either you or your doctor. Again, the letter MUST indicate the reason for the denial and explain your appeal options. For more information about your denial, you have the right to request a copy of everything your insurance company relied on in making their determination. Requests for such information should be made in writing and you should clearly state your request does not constitute your appeal (we usually write “THIS IS NOT AN APPEAL” at the top of the request).

 

Basis of Denial

There are two main categories of denials: medical necessity and experimental or investigational. Medical necessity involves proving you meet the requirements for treatment. Experimental/investigational involves showing the requested treatment is safe and effective based on current research studies and medical journal articles, and that it is medically necessary.

You should look at your insurance policy. If the denial is based on policy language, you’ll want to see the language. You should search your insurer’s Web site, usually in the members’ area, to look for their medical policies, called “clinical policy bulletins” (CPBs). These are detailed papers written by or for insurers that outline all of the coverage policies, including citations to medical journal articles and other sources your insurer relied on in making their decision. The CPB will tell you what factors are considered in determining medical necessity.

For example, one insurance company’s CPB regarding the use of formulas and enteral nutrition (EN) states it covers them when the requested formula/EN is expected to provide more than 50 percent of the member’s daily caloric intake. So, if you receive a denial under this plan stating EN is not medically necessary, you would need to provide documentation (medical records) showing that you meet the 50 percent threshold.

If there is an express exclusion for a particular treatment in your policy, like over-the-counter nutritional supplements, your insurance most likely won’t cover it and an appeal would be unsuccessful.

 

Preparing Your Appeal

If your denial was based on medical necessity, you’ll need to collect your medical records in order to explain why the treatment is medically necessary. You should collect relevant office notes, x-ray reports, blood tests, other diagnostic tests, and hospitalization records. This provides the insurance company objective medical information to back up your subjective description of symptoms.

If your denial was based on experimental/investigational, in addition to collecting your medical records, you must also show support for the use of the treatment in the medical literature. You can find medical journal articles at www.pubmed.gov or Google Scholar. Generally using your condition and treatment as search terms produces good results. Full text articles can be retrieved at medical libraries (typically at your state university) for free, or you can pay per article online. Abstracts of the articles, which are free online, can be used in place of full text articles if you are unable to obtain the full text copy. It sounds super technical, but spend some time reading abstracts and you’ll quickly figure out how to read and understand the results.

 

Deadlines

Appeal filing deadlines are very important. Typically you have 180 days from the date of the denial to file your first-level appeal. If your insurance company upholds its denial, you may have to file a second-level appeal before proceeding to external review (if available). The second-level deadlines can be much shorter.

This information should be contained in your denial letter, but you can also find out by contacting the customer service number on the back of your insurance ID card. You have 120 days (or four months) to file for an external review. External reviews are conducted by organizations independent from the insurance company and we have had a lot of success at this level. However, missing a deadline cuts off your eligibility for further review, so it is very important to keep track of deadlines.

 

Outline of the Appeal Letter

Once you’ve collected all of the necessary documents, it’s time to write your appeal letter. You should include the following elements.

Identifying information: include the patient’s name, insurance ID number, Social Security number, and date of birth, as well as a claim reference number if one was provided.

Medical necessity summary: if you have information from the CPB, format this section of your appeal letter to match the format used in the policy. Start with the diagnosis, including objective support in the medical records like weight loss, recent test results, radiology reports, etc. Then identify what treatments have been tried and failed. This is an important step for both medical necessity and experimental/investigational appeals because it shows that the treatment requested is the only/best option available.

If you are filing an experimental/investigation appeal, you need to address the medical literature. You want to start with the strongest support, which would be randomized, placebo-controlled studies, and then branch out to the less persuasive articles, like review articles. Sometimes you can include other insurance companies’ policies that allow for the treatment you are appealing, especially if it is an affiliate of your insurance company (like the Blue Crosses). You will also need to include a medical necessity summary to show why the treatment/procedure is indicated for the patient (you) at this time. You can outline symptoms, flare-ups, negative reactions, etc., documented in the medical records. You can also reference any recommendations in the medical records from your treatment providers.

 

Resources

Keep in mind that your health care provider is a great resource when appealing a denial. If you offer to take the burden of writing the appeal off his or her shoulders, it will be easier to get his or her help reviewing medical literature and analyzing insurance medical policies. You can often get letters detailing the medical necessity directly from your provider as well. Just ask.

For more information on how to file appeals and other resources, please visit the Jennifer Jaff Center Web site at www.thejenniferjaffcenter.org or call (860) 674-1370.

LifelineLetter, March/April 2014

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5/6/2017
Oley Regional Conference

This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.

 

Updated in 2015 with a generous grant from Shire, Inc. 

 

This website was updated in 2015 with a generous grant from Shire, Inc. This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.
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