Dr. De Smet 2006

Insurance Appeals 101

For those of you who have not had experience with insurance
appeals, here’s a couple of tips I learned helping patient families
with insurance appeals:

(1)First and foremost, read your policy – the full document
with all
of the legalese, not just the coverage pages. Your employer
should
have a copy of the policy or coverage book or you can
usually get it
directly from the insurance company. My full document is 152
pages (8
1/2 x 11″) and was available on the website for my insurance
plan.

(2)Read the entire document (hey you’re probably not
sleeping anyway
if you need a new hip and this reading is much more
effective than a
sleeping pill..), but pay particular attention to key terms
that could
be used to deny coverage in the policy –
a.under `exclusions’ what’s listed (investigational or
experimental,
out of state or out of country unless for emergency
treatment, and any
other pertinent language). Always read the entire
‘limitations and
exclusion’ section carefully looking for anything that
applies to your
situation.
b.in the glossery – the definition of investigational/
experimental,
any definitions pertaining to out of country or out or
state, for out
of country procedures — the definition of a ‘hospital’ and
the
definition of a physician/surgeon, and any other pertinant
terms.
c. somewhere in the main text look for requirements re:
preauthorization and specialist referrals, and be sure that
you’ve
done them.
c. the appeal process rules — almost all insurances have a
within
company and external appeal process

(3)Read the appeal letter and look for the stated language
for ‘reason
of denial’. Look up that language in the glossery. (i.e. if
it was
denied for being investigational, check the glossary
definition of
investigational.)

(4) Write down all calls, dates, information and the name of
the
person to whom you spoke.

(5) If you’ve determined that the contract actually does
seem to
specify coverage and the insurance company is denying it
anyway, and
you work for a larger company, see if the human resources
benefit
department will help. To the insurance company, the
purchasurer of
the insurance (i.e. your employer) is the customer. They
won’t want
to lose their business. The user (i.e. you) is not as
influential as
the purchaser.

(6) The biggest mistake people make in trying to appeal
insurance
decisions is going by “logic” vs. by the policy language.
Basically
the policy is a legal contract. The insurance company is
saying that
the contract they have with you does not provide coverage
under the
terms of your contract. You want to demonstrate that the
contract
terms do, ACCORDING TO THE CONTRACT NOT ACCORDING TO LOGIC,
stipulate
coverage.

Here’s some examples from my policy of contract language:

Preauthorization means approval by us, our designee of a
service prior
to it being provided. Certain services require medical
review by us
in order to determine eligibility for coverage.
Preauthorization is
granted when such a review determines that a given service
is a
covered expense according to the terms and provisions of the
policy.
(Here you’d look up the definition as well of ‘medical
review’ so you
knew what you were in for.)

‘Medically necessary’ has a two definition paragraph in my
glossary
that includes, among other things this statement “Supported
by the
preponderance of nationally recognized peer review medical
literature,
if any, published in the English language as of the date of
service.”
So, if the denial was due to not “medically necessary”, I’d
want to
find as many studies as possible, in peer reviewed English
language
journals, preferably published in the US, but I’d include
other
reputable English language journals that published British
results as
well and submit those with the appeal. It also says, “In
accordance
with nationally recognized standards of medical practice and

identified as safe, widely used and generally accepted as
effective
for proposed use.” Note the key word “nationally”
NOT “internationally”. So if I was appealing this, I’d
include
information about how many surgeons are now trained or in
process of
training for this procedure (perhaps available from the BHR
folks) in
the UNITED STATES, not internationally, as the contract
states the
criteria as national, not international, standard of care.

OK, if I haven’t bored you to death yet, one last
example: ‘Experimental or investigational or for research
purposes’
in my policy is defined as “a drug, biological product,
device,
treatment or procedure that meets any of the following
criteria, as
determined by Humana Insurance Company:
— Cannot be lawfully marketed without the final approval of
the FDA
(then several possible exceptions are listed)
— Is a device required to receive Premarket Approval (PMA)
or 510K
yet has not
–Is not identified as safe, widely used and generally
accepted as
effective for the proposed use as reported in nationally
recognized
peer reviewed medical literature published in the English
language as
of the date of service
–Is the subject of (list of specific phases and types of
cancer
studies)
–Is identified as not covered by the centers for Medicare
and
Medicaid Sercies (CMS) Medicare Coverage Issues Manual (then
a list of
other possible CMS denial standards)

So with FDA approval, and medicare coverage, and studies
supporting
its use, I’d have a very good chance of winning an appeal
with a BHR
device with this company due to its language if they said it
was
denied due to investigational status. However, if I went
with a C+
hip device, and they denied for the same reason, I’d
probably lose as
it is not yet FDA approved. I might have a change for an
appeal under
medically necessary if the BHR cup did not fit and one of
the other
cups did, hence, my surgeon used another cup.

Hope this helps a bit.

Michelle
Madison, WI