Responding to Health Insurance Denial Arguments

"The denial states the treatment is 'not medically necessary,' but fails to account for my specific medical condition and circumstances. My treating physician, Dr. [Name], a board-certified [Specialty], has determined this treatment is medically necessary based on [specific clinical reasons]. California law requires the insurer to give appropriate weight to my physician's recommendation. I request the specific clinical criteria used to deny this claim and the qualifications of the reviewer who made this determination. Under Health & Safety Code § 1367.01, this decision must be based on evidence-based clinical criteria appropriate to my condition."

"The insurer's claim that [treatment] is 'experimental' is inaccurate. This treatment is [FDA-approved / standard of care / supported by peer-reviewed literature]. Attached please find [number] peer-reviewed studies demonstrating the safety and efficacy of this treatment for conditions like mine. The treatment is recommended by [medical society/organization] and is routinely performed at major medical centers. California law narrowly defines 'experimental,' and this treatment clearly does not meet that definition."

"The denial for lack of prior authorization should be reconsidered because: [Choose applicable] (1) This was an emergency situation where prior authorization was not feasible; (2) My provider was responsible for obtaining authorization and their administrative error should not result in denial of my medically necessary care; (3) I was not properly informed that this service required prior authorization; (4) I request retrospective authorization as the treatment was medically necessary and would have been approved if prior auth had been requested. Please review this claim on the merits of medical necessity."

"I am appealing the out-of-network denial because [choose applicable]: (1) There is no qualified in-network provider within reasonable distance or timeframe for my condition - I searched the provider directory and the nearest in-network [specialty] is [X miles away / has a [X week] wait time]; (2) This was emergency care which must be covered regardless of network status; (3) I received care at an in-network facility and was not informed the provider was out-of-network, entitling me to protection under AB 72; (4) My established provider left the network mid-treatment and continuity of care protections apply. Please process this claim at in-network rates."

"This denial citing a pre-existing condition exclusion appears to violate federal law. Under the Affordable Care Act (42 U.S.C. § 300gg-3), health insurance plans are prohibited from denying coverage based on pre-existing conditions. My plan, issued on [date], is subject to ACA requirements. Please immediately reverse this denial and process my claim. If you believe my plan is exempt from ACA requirements, please provide specific legal authority and documentation of my plan's exempt status."

"I dispute the denial stating this service is not covered. [Choose applicable]: This service falls within the Essential Health Benefits that all ACA-compliant plans must cover, specifically [category]. / This mental health service must be covered at parity with physical health services under federal and California mental health parity laws. / This service may have been miscoded - please review the attached documentation showing the correct service classification. / California Health & Safety Code § [cite] mandates coverage of this service. Please review my plan's Summary of Benefits and Coverage and Evidence of Coverage to confirm this service is covered."

"I am appealing the coding-related denial. I have contacted my provider and confirmed the codes accurately reflect the services rendered. [If applicable: The attached corrected claim should be processed. / The services were distinct and should not be bundled - please see the attached modifier documentation. / The codes used are appropriate for the documented diagnosis.] Please reprocess this claim."

"I dispute the denial based on reaching a benefit maximum. [Choose applicable]: This dollar limit appears to violate the ACA's prohibition on annual and lifetime limits for essential health benefits. / The visit limit applied to my mental health treatment violates mental health parity requirements, as there is no comparable limit for analogous medical/surgical benefits. / I request an exception to this limit based on medical necessity - my treating provider has determined continued treatment is necessary for my condition. Please provide specific information about how this limit complies with federal and state law."

"I appeal the denial for untimely filing because [choose applicable]: (1) I have attached proof that the claim was timely filed on [date] - see [fax confirmation/certified mail receipt/electronic confirmation]; (2) Good cause prevented timely filing - [explain circumstances]; (3) The filing deadline should be calculated from [correct date], not [date used by insurer]; (4) My provider was responsible for claim submission - please contact them directly or provide me documentation to pursue a claim against them. Please reprocess this claim."

"I dispute the duplicate claim denial. [Choose applicable]: These are distinct services - please see the attached documentation showing [different dates/different services/different providers]. / I have no record of receiving payment for this claim - please provide documentation of the payment you allege was made, including date, amount, and payment method. / Please review the dates of service carefully as this claim is for [date] which is distinct from [other date]."