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Posted on 15. March 2012

Not Medically Necessary

By Tammie Allegro

I felt like a young adult waiting to hear whether I got accepted to Yale. Actually, it was more like I was a girl who survived pledge week for an elite sorority waiting for her pin. I had done everything I needed to do, and now I just needed them to tell me I was "accepted." This is why I almost burst into tears when I read the words: "Claim denied. Reason; not medically necessary." So I didn't get in? I can't have a medical test done because some person sitting at my insurance company decided I don't need it? I find it interesting that the same insurance company approved a referral to the specialist for treatment, but not the test that would tell me if I need a specialist in the first place. What am I going to do now? How do I get this approved? Can I get this approved?

I probably would have kept crying and feeling sorry for myself if I wasn't so educated about the appeals process. My knowledge comes from all the IG Living articles, blogs and posts on Facebook by patients and experts, I knew my next step was to file an appeal. I started researching past articles in IG Living magazine to see if there was information about how to submit an appeal to an insurance provider. Here is what I found in the December-January 2011 issue in an article titled "How to Write an Effective Appeal Letter":

  1. Don't Give Up; Appeal: Filing an appeal can be stressful and frustrating for even the healthiest people. For those with chronic illness, having to fight for lifesaving treatment on top of battling disease can be a daunting task.
  2. A Proper Approach for Appeal: To help ensure a successful appeal, proper steps need to be followed. Be forewarned: A person should never take the seemingly easy route when filing an appeal.
  3. Before the Appeal Is Filed: Before writing an appeal letter, it's important to gather some information.
    1. Coding errors. An American Medical Association study revealed that one out of five medical claims contains errors.
    2. Treatment policies. It used to be that a doctor could write a script for a diagnosis, and treatment would be given - no questions asked. That is no longer the case.
    3. Plan types. There is a difference between a fully insured and self-funded insurance plan.
  4. Submitting the Package: When making an appeal, it is important for a complete package to be submitted. A complete package includes:
    1. Name, date of birth, subscriber number and contact information
    2. Letter of medical necessity from the prescribing doctor detailing the diagnosis and need for treatment
    3. Lab reports and test results.
    4. Doctor's notes detailing treatments that have been tried and failed
    5. Peer-reviewed articles supporting immune globulin as a treatment for the disease
  5. The Timeline: Nothing will lose an appeal faster than not sticking to the allotted timeline.

Knowing that I have options made me feel a lot better about receiving the rejection letter. I know now that I must file the appropriate appeal. Everyone deserves to have the medical testing and treatments that are available to help save or preserve the life they have. In fact, they have the right not just to preserve that life, but possibly to improve it as well. The truth is these doctors and insurance companies do make decisions based on what the "rules" say are medically necessary. It is up to us as patients to point out to them that medical decisions must be made on a case-by-case basis. If more of us appeal these types of decisions, maybe healthcare providers and insurance companies will begin to review and possibly rewrite the rules that keep patients from accessing the care they need.

Something else that helped in this process was the knowledge that I wasn't alone. I have an entire community of people who understand and feel my pain. When I write my appeal letter, I will remember that I am fighting for myself and for everyone who has and who will ever have to walk the same path.  Have you written an appeal before? What was the result?


Comments (1) -

2:25 PM on Friday, September 06, 2013

I am really frustrated!!  I did everything right with my insurance and the appeal process but was still told that Ivig was not medically necessary for my cvid

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