Denied Medical Claims: How to Fight Back

Understanding Why Claims Get Denied

Health insurers deny claims for many reasons, ranging from legitimate coverage issues to questionable interpretations of "medical necessity." Understanding why your claim was denied is the first step to crafting an effective appeal.

Denial Reasons and How to Challenge Them

Your Right to Appeal

Federal law (the Affordable Care Act) gives you the right to appeal any denied health insurance claim. This applies to most health plans, including employer-sponsored plans, marketplace plans, and individual policies. You typically have at least 180 days from receiving the denial to file an appeal.

The Two-Level Appeal Process

Most health insurance appeals follow a two-level process:

1. Internal Appeal: You ask the insurance company to reconsider its decision. The appeal must be reviewed by someone not involved in the original denial.
2. External Review: If the internal appeal is denied, you can request an independent external review. An outside organization reviews the case and makes a binding decision.

How to Write an Effective Appeal

A well-written appeal dramatically increases your chances of success. Follow these steps to build the strongest possible case:

1. Read the denial letter carefully - Identify the specific reason(s) for denial. Note any deadlines and required procedures. Request a copy of your complete claim file and the criteria used to make the decision.
2. Get your medical records - Obtain all relevant medical records, test results, imaging studies, and physician notes. These will support your argument that treatment is necessary.
3. Request a letter from your doctor - Your treating physician should write a detailed letter explaining why the treatment is medically necessary for your specific condition. This is often the most important piece of your appeal.
4. Gather supporting evidence - Collect clinical guidelines from medical societies, peer-reviewed studies, FDA approvals, and any other evidence supporting your treatment.
5. Write your appeal letter - Clearly explain why the denial was wrong. Reference your policy language, cite the evidence, and request specific action (approve the claim, pay for treatment).
6. Submit within the deadline - Send your appeal by certified mail or the method specified in the denial letter. Keep copies of everything you submit.

Medical Necessity Appeals

"Not medically necessary" is the most common denial reason - and one of the most frustrating. Insurers use their own criteria (often proprietary guidelines) to determine medical necessity, and these criteria may be more restrictive than accepted medical practice.

What "Medical Necessity" Means

Generally, a treatment is medically necessary if it is:

• Appropriate for your symptoms, diagnosis, or condition
• Provided in accordance with generally accepted standards of medical practice
• Not primarily for the convenience of you or your provider
• The most appropriate level of service that can safely be provided

Challenging Medical Necessity Denials

• Request the criteria: Ask for a copy of the specific criteria the insurer used to deny your claim
• Compare to standards: Show that the treatment meets accepted medical standards and clinical guidelines
• Doctor's letter: Have your physician explain why alternatives would not work for your specific situation
• Prior history: Document failed attempts at alternative treatments
• Peer-to-peer review: Request that your doctor speak directly with the insurer's medical reviewer

ERISA Claims: Special Considerations

If you get health insurance through your employer, your plan is likely governed by ERISA (Employee Retirement Income Security Act). ERISA claims have different rules and stricter requirements than state-regulated plans.

Building an ERISA Appeal

Because ERISA limits what courts can consider, your internal appeal is critical:

• Include all evidence you want considered - you may not be able to add it later
• Get detailed letters from your physicians
• Submit relevant medical literature and guidelines
• Request all documents the plan relied on to deny your claim
• Identify any conflicts of interest (e.g., insurer both decides and pays claims)

External Review: Your Final Option

If your internal appeal is denied, you can request an external review. An independent organization (not affiliated with your insurer) will review your case and make a binding decision.

When External Review Is Available

• Your internal appeal was denied
• The denial involves medical judgment (medical necessity, experimental treatment)
• You file within 4 months of the internal appeal denial (varies by state)

Expedited External Review

You can request expedited external review if:

• Your life or health is in serious jeopardy
• The standard timeline would seriously jeopardize your ability to regain maximum function
• You are experiencing severe pain that cannot be managed without the treatment

Common Mistakes to Avoid

• Missing deadlines: Appeal deadlines are strict. Mark them on your calendar and submit early.
• Not reading the denial: The denial letter explains why the claim was denied and how to appeal. Read it carefully.
• Skipping the internal appeal: For ERISA plans, you must exhaust internal appeals before suing.
• Not getting physician support: A detailed letter from your treating doctor is often the most important piece of evidence.
• Giving up after one denial: Many claims are approved on appeal. Do not accept the first "no" as final.
• Not keeping records: Keep copies of everything you submit and receive. Track all phone calls with dates, names, and details.

When to Get Professional Help

Consider getting professional help with your appeal if:

• The claim involves a large amount of money or ongoing treatment
• Your life or health depends on getting the treatment approved
• The denial involves complex medical or legal issues
• You have been through one level of appeal without success
• You have an ERISA plan and need to build a strong administrative record