How to Win Health Insurance Appeals

Jennifer C. Jaff, Esq.
 

It would be impossible for me to tell you everything I know about how to take a health insurance appeal in 1000 words. But I can give you some pointers that will help you to present your case more effectively.

First, don’t just make a phone call or write a letter, or let your doctor write a brief letter. That is not enough. You need to put together a packaged appeal that addresses the issues in question with the support of objective evidence, i.e., test results, biopsies, labs, etc., as opposed to subjective evidence, i.e., reports of pain and other symptoms unless corroborated by objective evidence.

The Three Critical Steps

Step One: In the letter denying coverage for the treatment your doctors propose, there will be a statement offering to send you a copy of the entire file, including their internal clinical criteria. Take them up on it. Write a letter, quote the language from the denial letter, and ask that they send you the file. If you don’t hear within 30 days, start calling. I find that not all insurance companies really understand that this is a requirement of federal law, that they can’t pick and choose what they send you — it has to be the entire file, and that they have to include their internal criteria. You may have to explain that this is one of the requirements of ERISA, the federal statute governing employee benefits, as well as laws in many states.
 

Step Two: Gather objective medical evidence. I strongly urge patients to get copies of test results, surgical reports, hospital discharge summaries and so on as you go. It is easier to get your doctor to mail you one lab slip than it is to get a copy of your entire file. What you need for your appeal is evidence that establishes a) your diagnosis; b) your history (how long have you had the illness, what surgeries have you had and when); c) recent attempts to treat your disease (medications, surgeries, other therapies): and (d) the failure of these attempts.

If you are lucky enough to have a doctor willing to help, he or she could write a letter that addresses these points, but I would add test results and other objective proof to the doctor’s letter so that it’s clear that what your doctor says is proven by the medical evidence.

In some cases, in addition to medical records, you need to gather scientific information. For example, if you need Enterra therapy, and your insurance company denies coverage because it is unproven or experimental, you need to produce copies of peer-reviewed medical journal articles showing the effectiveness of the proposed treatment. Pharmaceutical and device manufacturing companies will give you this material upon request.
 

Step Three: Write the appeal letter. This often surprises people, but if you want to win an insurance appeal, you don’t just send your medical records and hope. You have to make the argument. You’re very sick (citing to objective evidence such as weight loss or blood work showing malabsorption, for example); you’ve tried everything else (also citing to evidence of what you have tried); nothing has worked (again, citing to attached records); and your doctor thinks this treatment is worth a chance for certain logical reasons.

As to this last, most crucial point, start with the clinical criteria that the insurance company sends you. What you have to argue is that the evidence shows that you meet those criteria. Sometimes, going through each item on their criteria, labeling each paragraph accordingly, is an excellent way to organize your appeal.

Federal law also requires that the insurance company provide you with a reason for the denial that is clear enough that you can focus your appeal accordingly. For example, if they say “the treatment is not warranted according to our clinical criteria,” that is not enough — that could be said of every denial. You have a right to a clearer answer.

Recently, I got a denial on the ground that a certain medication is not FDA approved. The patient has Crohn’s disease. There are only two drugs that are FDA approved for Crohn’s disease: prednisone and Remicade. Yet all insurance companies pay for a host of other drugs for the treatment of Crohn’s disease despite the fact that they are not FDA approved. (This is called an off-label use). So I called the insurance company, got the person who signed the denial letter on the phone, and said, “I know that this can’t be your real reason because you pay for all of these other drugs that aren’t FDA approved for treating Crohn’s disease, so now tell me your real reason.” I was told that there weren’t enough medical records in their file. Now, I know how to handle that appeal.

Insurance companies are not used to seeing appeals packaged like this. I recall one recent instance in which I spoke with the insurance company by phone, told them I would be taking an appeal, and they asked if I wanted them to send the file up to their appeals department. They expressed surprise when I said that I would be making a submission to the insurance company that would include evidence and argument. Taking the process more seriously than most people do will make your appeal stand out.

Of course, when we patients have to do this sort of work to get treatment it is most often the time when we feel the sickest. Unfortunately, in our health care system, being sick can be very hard work. However, these issues are a necessity.

So maintain your medical records, read about your medications, treatment, and disease (the internet is an amazing source of everything you ever wanted to know and then some), and make sure you understand the decisions that are being made for your care. If you are an active participant in your health care, writing appeals will be far easier for you.
 

Finally, when all else fails, you may wish to contact me at patient_advocate@sbcglobal.net. Or you can purchase my book, Know Your Rights: A Handbook for Patients with Chronic Illness, on my website, www.advocacyforpatients.org. The book contains far more information than I can provide in the space allotted here, along with sample appeal letters, including one successful appeal from a denial of coverage of Enterra therapy. These and other tools are things you should be gathering all the time, regardless of whether, at that time, you need them. If you do so, when you get your next denial, you will be ready to go forward with your appeal, armed with information and educated about how to present it.  

Jennifer C. Jaff is an attorney in Hartford, CT who is the Executive Director of Advocacy for Patients with Chronic Illness, Inc. She has written Know Your Rights: A Handbook for Patients with Chronic Illness, available for purchase at www.advocacyforpatients.org. Reprinted with permission from Association of Gastrointestinal Motility Disorders’ (AGMD) Digestive Motility Forum Volume I, Number Two - November 2005.