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Lymphedema How to Appeal Insurance Denials

This page has been updated, please see:

How to File A Health Insurance Appeal

http://www.lymphedemapeople.com/wiki/doku.php?id=how_file_a_health_insurance_appeal

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Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe: AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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A problem, we who have lymphedema often face are denials from insurance companies.

At this time, there is no uniform national standard for the treatment of our condition.  Many insurance companies will pay for therapy, but not compression garments or equipment.  Others may give you trouble with needed diagnostics tests and/or present problems when it comes to treating  complications.

If you are denied coverage, don't just accept that denial.  You can and should appeal any insurance company decision you disagree with.

This section will provide information on how to appeal, the steps, necessary documentation and links for further assistance.

Wanted to especially thanks Tina for providing several top notch samples of appeal letters!!!

Also, wanted to share an except from a letter one of our members send regarding insurance denials.  This is from Cyndi Oritz, CCT from Nevada:

Also Pat, one thing people can do that most don't know about, is if the decision to treat is made by anyone who is not a licensed physician they can file a complaint with their local medical Board.  Anytime someone changes doctor's orders or denies treatment that is called "Practicing Medicine without a license". 
 
If the decision to deny is made by a licensed physician, then it may be "diagnosing and/or practicing medicine without examining the patient". 
 
We have had success with getting approvals going that direction.  I have a letter from the Nevada Board's attorney that outlines how that is illegal in this state, and believe me, I use the heck out of it.  I have had two denials recently that were ridiculous. One stated denial was due to the patient not elevating enough.  The other was due to patient not trying pool therapy as a conservative method of treatment.  I have alos had several stating they did not agree with the diagnosis of lymphedema and believed the patient was just obese. I faxed that letter and had approvals within a few hours

In addition:

A consumer can also file a complaint with their state's Attorney General alledging consumer fraud.  If they are paying for insurance, and treatment is avialable under their policy,  (whether it be physical therapy or Durable Medical Equipment, which all modalities of external compression fall under that category), then they have the right to obtain what the policy allows.  If they do not, they can also go at it from the "attempt to defraud consumer by making inappropriate denial for coverage" - "breach of contract", approach. They are going to want to see that the insured went through the insurance company's internal appeals process first though

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HMO Crises Update

http://www.deepdyve.com/lp/psycarticles-reg/the-hmo-crisis-01MmKUdi4e

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Appealing Health Insurance Denials

by Heidi Frey

Getting your medical expenses covered by your health plan can be frustrating, but a little knowledge can go a long way

The Basics

You can start by checking the following on your health plan:

Donít Be Stopped By Denials

should consider appealing if:

Call the company that issued the denial, armed with a file of your medical and insurance information, including your benefit plan and summary.

A customer service representative canít overturn your denial, so ask to speak with a supervisor.

Making a Formal Appeal

Every managed care organization is required by law to have an appeal process.

Although an appeal process isnít perfect, itís much less of a financial and emotional burden than litigation. And your contract with the health plan may prohibit you from filing a lawsuit before filing an appeal.

When formally appealing:

Getting Help

Your state Department of Insurance (DOI) has a wealth of information, including your rights regarding health insurance, the appeals process, whom to contact regarding an appeal and a general timeline for an appeal.

You should be able to locate your stateís DOI in the White Pagesí state government section under "Insurance" or "Regulatory Agencies." Your state governmentís home page should have a link to the DOI.

If you have questions regarding the mechanics of the appeals process:

Whatís Next

If the cost of the denial is enough to offset legal fees, it may be best for you to speak with an attorney who has experience with health care coverage and benefit denials.

Heidi Frey founded the Patient Advocacy Coalition in Denver, Colorado.

Link no longer available

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How to Appeal an Insurance Denial - Sample letter

[Date]

[your Medical Group or HMO]

ATTENTION: Customer Service/Appeals Department

[address]

RE: URGENT APPEAL for [Your name]

Member # [your HMO identification number]

Dear Customer Service/Appeals Department,

I am writing to appeal [Medical Group or HMO] decision to deny authorization for [name of treatment and/or diagnostic test requested] for me. The [Medical Group or HMO] has denied coverage for [Name of treatment and/or diagnostic test requested] as "not a covered benefit" under my plan. I believe [Name of treatment and/or diagnostic test requested] is medically necessary to [treat or diagnose] my medical illness and is a covered plan benefit. [Medical Group or HMO] should approve and authorize [Name of treatment and/or diagnostic test requested] in my case.

Failure to provide [IMMEDIATE TREATMENT OR REQUESTED TEST] for my illness envokes imminent and serious threat to my health. I am, therefore, requesting an expedited MD review of my appeal for BENEFIT coverage. Please provide me with a decision as soon as possible and no later than five days from the date of this appeal.

[your Medical Group or HMO] covers medically necessary services that are not specifically excluded, in addition to services specifically included under the plan terms. [your Medical Group or HMO] definition of medically necessary is found on [page #] of my [Evidence of Coverage or Summary Plan Description]. Medically necessary is defined as: [insert descriptions from handbook]

[Name of treatment and/or diagnostic test requested], for addressing my condition, falls within this definition. The plan excludes treatments. Procedures and diagnostic tests listed on [page #] of my [Evidence of Coverage or Summary Plan Description]. [Name of treatment and/or diagnostic test requested] is not listed as an exclusion or limitation under my health plan coverage.

[Name of treatment and/or diagnostic test requested] is recommended for my medical condition by [physician/specialist in Medical Group or HMO] and is considered medically necessary to [treat or diagnose] my condition. In fact, [Name of treatment and/or diagnostic test requested] is within the standard of sound clinical practice. [your Medical Group or HMO] failure to provide [Name of treatment and/or diagnostic test requested] violates our states "mandated benefit laws".

I am suffering from [name of condition OR "an undiagnosed condition"] and it affects my ability to conduct activities of daily living. I have previously received [types of other treatments you have tried AND/OR diagnostic tests you have undergone, if any] to [address AND/OR diagnose] my condition. However, my health problems have not been resolved. [Name of treatment and/or diagnostic test requested], I will continue to experience these and worse [problems]. If left [untreated or undiagnosed], my condition may require even more complex and costly treatment in the future. I have included documentation of my medical condition, and information supporting the medical necessity of [Name of treatment and/or diagnostic test requested], with this letter. Please let me know if any additional information will be helpful to my request. I can be reached at [telephone number].

Thank you for your immediate attention to this matter.

Sincerely,

[your name]

cc: [Medical Director of Medical Group or HMO]

[your primary care physician and specialist]

[your employer, insurance broker or plan manager]

[your state HMO insurance or regulatory agency]

Attachments: Letters from doctors supporting medical necessity, referrals, copy of medical record, copies from HMO Evidence of Coverage (EOC) concerning coverage and medical necessity, medical journal articles supporting medical necessity of care sought

How to Appeal an Insurance Denial

www.memag.com/hostedfiles/clipcopy0509.pdf

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How to Appeal an Insurance Denial - Sample letter for services outside your plans range 

[Date]

[your Medical Group or HMO]

ATTENTION: Customer Service/Appeals Department

[address]

RE: URGENT APPEAL for [Your name]

Member # [your HMO identification number]

Dear Customer Service/Appeals Department,

I am writing to request [Medical Group or HMO] the authorization to obtain services outside contracted area for my medical care. Specifically, I request the authorization for access to [name of medical center, hospital, or institution] for the treatment of my illness. My current [Medical Group or HMO] physician [name of your doctor] has diagnosed me to have [name of illness] and is suggesting immediate procedural treatment. I am convinced that [name of medical center, hospital, or institution] will provide me the highest quality medical care for my condition and it is therefore medically necessary that I obtain authorization as soon as possible. I understand that [Medical Group or HMO] maintains contracts with [name of medical center, hospital, or institution]. Please immediately change my primary care provider and Specialist to a [Medical Group or HMO] physician that has access to[ name of medical center, hospital, or institution]. [Medical Group or HMO] should allow this immediate request to obtain services outside contracted area.

Failure to provide ME IMMEDIATE ACCESS TO [NAME OF MEDICAL CENTER,HOSPITAL, OR INSTITUTION] for my illness envokes imminent and serious threat to my health. I am, therefore, requesting an expedited MD review of my appeal for APPROVAL OF MY REQUEST. Please provide me with a decision as soon as possible and no later than three days from the date of this appeal.

I am attaching documentation of my medical condition, and information supporting the medical necessity of my request for services outside contracted area. Please let me know if any additional information will be helpful to my request for coverage. I can be reached at [phone #].

Thank you for your immediate attention in this matter.

Sincerely,

[your name]

cc: [Medical Director of Medical Group or HMO]

[your primary care physician and specialist]

[your employer, insurance broker or plan manager]

[your state HMO insurance or regulatory agency]

Attachments: Letters from doctors supporting medical necessity, copy of medical record, copies from HMO Evidence of Coverage (EOC) concerning prescription drug coverage, medical journal articles supporting medical necessity of care sought.

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Sample letter to appeal insurance decision against treatments 

[Date]

[your Medical Group or HMO]

ATTENTION: Customer Service/Appeals Department

[address]

RE: URGENT APPEAL for [Your name]

Member # [your HMO identification number]

Dear Customer Service/Appeals Department,

I am writing to request [Medical Group or HMO] to authorize my medical care be administered by a Specialist. [Medical Group or HMO] has delayed or denied my doctorís referral request for me to see a [type of Specialist, name of Specialists]. My primary care physician [name of your doctor] has diagnosed me to have [name of illness] and it is medically necessary that I see a Specialist as soon as possible. I further request that this specialist [type of Specialist, name of Specialists] be given adequate opportunity to oversee my care until such time as to the resolution of my illness . [Medical Group or HMO] should allow my immediate request to see a specialist..

Failure to provide ME THE OPPORTUNITY TO SEEK THE TREATMENT OF A SPECIALIST for my illness envokes imminent and serious threat to my health. I am, therefore, requesting an expedited MD review of my appeal for APPROVAL OF MY SPECIALIST REQUEST. Please provide me with a decision as soon as possible and no later than five days from the date of this appeal.

I am attaching documentation of my medical condition, and information supporting the medical necessity of my Specialist referral. Please let me know if any additional information will be helpful to my request for coverage. I can be reached at [phone #].

Thank you for your immediate attention in this matter.

Sincerely,

[your name]

cc: [Medical Director of Medical Group or HMO]

[your primary care physician and specialist]

[your employer, insurance broker or plan manager]

[your state HMO insurance or regulatory agency]

Attachments: Letters from doctors supporting medical necessity, copy of medical record, copies from HMO Evidence of Coverage (EOC) concerning prescription drug coverage, medical journal articles supporting medical necessity of care sought.

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Sample letter for a Second opinion 

Date]

[your Medical Group or HMO]

ATTENTION: Customer Service/Appeals Department

[address]

RE: URGENT APPEAL for [Your name]

Member # [your HMO identification number]

Dear Customer Service/Appeals Department,

I am writing to request [Medical Group or HMO] the authorization to obtain a Second Opinion referral for my medical care. In order to assure the objectivity of this appointment, I request to see a [type of Specialist] from outside the [Medical Group or HMO] organization. My current [Medical Group or HMO] physician [name of your doctor] has diagnosed me to have [name of illness] and is suggesting procedural treatment. It is therefore medically necessary that I obtain a Specialist Second Opinion as soon as possible. I further request the opportunity to suggest the name of this specialist [type of Specialist, name of Specialists]. [Medical Group or HMO] should allow my immediate request for a second opinion.

Failure to provide ME THE OPPORTUNITY TO SEEK AN OBJECTIVE SPECIALIST SECOND OPINION for my illness envokes imminent and serious threat to my health. I am, therefore, requesting an expedited MD review of my appeal for APPROVAL OF MY SECOND OPINION REQUEST. Please provide me with a decision as soon as possible and no later than five days from the date of this appeal.

I am attaching documentation of my medical condition, and information supporting the medical necessity of my Second Opinion referral request. Please let me know if any additional information will be helpful to my request for coverage. I can be reached at [phone #].

Thank you for your immediate attention in this matter.

Sincerely,

[your name]

cc: [Medical Director of Medical Group or HMO]

[your primary care physician and specialist]

[your employer, insurance broker or plan manager]

[your state HMO insurance or regulatory agency]

Attachments: Letters from doctors supporting medical necessity, copy of medical record, copies from HMO Evidence of Coverage (EOC) concerning prescription drug coverage, medical journal articles supporting medical necessity of care sought.

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Fighting a Health Insurance Claims Denial

http://healthinsurance.about.com/od/claims/a/fighting_claim_denials.htm

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"Can I appeal my managed care or insurance carrier's refusal to pay for services?"

http://healthyparent.com/ins-appeal.html

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Fighting health-insurance claim denials

One of these days, you might have to battle your health insurance company over a denial of coverage.

Of course, most people would rather skip the fight, and there are steps you can take to avoid health insurance denials before they occur.

And if that doesn't work, there are steps you can take to fight them once they do.

The key is organization -- having all your paperwork in order, taking detailed notes of your interactions with everyone in the process and understanding your coverage.

Knowledge -- your best weapon

Information is power, and this is never truer than when battling a health care system. The winner may be the side with the better-organized, more-detailed information.

Some experts feel that legislation is tilting the regulatory environment in the patients' favor.

"



http://www.oag.state.md.us/consumer/edge75.htm

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NLN - Draft of Insurance Appeal Letter

http://www.lymphnet.org/insuranceletter.html

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Medical Necessity Statement

Lymphedema garments and bandages

http://www.jovipak.com

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Insurance Reimbursement Information

Circaid

http://www.lymphedema.biz/Insurance/InsReimPkg.pdf

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The Alliance of Claims Assistance Professionals

Offers assistance in getting insurers to pay for experimental treatments, as well as other reimbursement and billing problems

Toll-free 877-275-8765

http://www.claims.org

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Center for Patient Advocacy

Has an insurance-help hotline. CPA can serve as an alternative to litigation for patients who are denied coverage

800-846-7444

http://www.patientadvocacy.org

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National Insurance Consumer Helpline

A general information source for all types of insurance-related issues, including life and health insurance

800-942-4242

Primary address:

National Insurance Consumer Helpline 
1001 Pennsylvania Avenue NW, 
Washington, DC 20004 
Phone: (800) 942-4242 
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Patient Advocate Foundation (PAF)

800-532-5274

help@patientadvocate.org

This organization serves as an active liaison between the patient and their insurer, employer and/or creditors to resolve insurance, job discrimination and/or debt crisis matters relative to their diagnosis

http://www.patientadvocate.org

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See also:

Lymphedema and insurance companies

http://www.lymphedemapeople.com/thesite/lymphedema_and_insurance_companies.htm

Lymphedema Insurance Billing Guidelines

http://www.lymphedemapeople.com/thesite/lymphedema_insurance_billing_guidelines.htm

Lymphedema Letter of Medical Necessity

http://www.lymphedemapeople.com/thesite/lymphedema_letter_of_medical_necessity.htm

Lymphedema How to Appeal Insurance Denials

http://www.lymphedemapeople.com/thesite/lymphedema_how_to_appeal_insurance_denials.htm

How to fight your insurance company

http://www.lymphedemapeople.com/forum/topic.asp?TOPIC_ID=845

State Insurance Commissioners

http://www.lymphedemapeople.com/thesite/lymphedema_advocacy_insurance_comm.htm

Insurance Coverage for the Treatment of Lymphedema

http://www.lymphedemapeople.com/thesite/lymphedema_insurance_coverage_for_treatment.htm

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For information about Lymphedema

http://www.lymphedemapeople.com/thesite/all_about_lymphedema.htm

For Information about Lymphedema Complications

http://www.lymphedemapeople.com/thesite/lymphedema_complications.htm

For Lymphedema Personal Stories

http://www.lymphedemapeople.com/forum/forum.asp?FORUM_ID=7

For information about Lymphedema Wounds

http://www.lymphedemapeople.com/thesite/lymphedema_wound_care_revised.htm

For information about Lymphedema Treatment Options

http://www.lymphedemapeople.com/thesite/lymphedema_treatment_options_revised.htm

For information about Lymphedema and Exercises

http://www.lymphedemapeople.com/thesite/lymphedema_exercise_excercises.htm

For information on Infections Related to Lymphedema

http://www.lymphedemapeople.com/thesite/lymphedema_types_of_infections.htm

For information about Children's Lymphedema

http://www.lymphedemapeople.com/thesite/lymphedema_childrens_pediatric.htm

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Lymphedema Glossary

http://www.lymphedemapeople.com/forum/topic.asp?TOPIC_ID=247

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At our home page we have 18 categories with 218 articles

on lymphedema, edema, and related conditions:

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                      Advocacy and Lobbying Resources

                      Resources for the Medical Community

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Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe: AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

================================

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Updated Dec. 28, 2011