Arguments To Use Against An Insurer's Denial Of A Health Claim

In general, health insurance does not pay for any treatment or procedure that is not "medically necessary."

Your goal is to prove that the treatment, service or procedure you want is appropriate, effective, and necessary for the stability, or restoration, of your health.

Build your case before submitting your appeal - while making sure to appeal within the time frame specified in your coverage. (If you can't build all your case before the deadline, submit what you have. You can add more as you learn it).

To build your case, find out:

• If other specialists or health professionals in the area are using the procedure, service or treatment for medical situations like yours.
• If the procedure, service or treatment is being used in other regions of the country for medical situations like yours. "Standard" medical procedures can vary by region.
• If your national or local disease specific nonprofit organization has information on the use of this procedure, service or treatment with your diagnosis. If so, how often is it used and by whom? (The more respected the person or organization that uses the procedure, service or treatment, the better).
• If the procedure, service or treatment has been covered in any peer reviewed medical journals. [A peer reviewed journal is one in which articles are reviewed by experts (peers) before publication. One of the best known peer reviewed journals is JAMA -- the Journal of the American Medical Association]. These journals can be obtained from your local library, a nearby medical school library or on the Internet. Do they support this use of the procedure, service or treatment in question?
• Is this procedure being used for people with your diagnosis in other medically advanced countries such as Canada, countries in Europe or Israel? Many treatments, services and procedures have been used outside the U.S. before being approved by the FDA.
• If members of your support group (if you have one) know about using this procedure, service or treatment. People with a particular medical condition are often better informed about treatments and results than doctors.

When you write your appeal letter, ask that your claim be reviewed by the insurer's medical director or staff doctor. Even though paid by the insurer, a doctor is more likely to back good patient care. 

Following is a list of sites that may provide the information you need.

For treatments, services or procedures

• PubMed (from the National Institutes of Health): www.ncbi.nim.nih.gov/sites/entrez  (for a tutorial on how to use PubMed, click here. )
• Annals of Internal Medicine (from the American College of Surgeons): www.annals.org
• Journal Of The American Medical Association: http://jama.ama-assn.org/
• National Guideline Clearinghouse (US Department of Health and Human Services): www.guideline.gov  (a public resource for evidence-based clinical practice guidelines. Check the date of guidelines before using to be sure they are current).
• National Institutes of Health: http://www.nih.gov/
• The New England Journal of Medcine: http://content.nejm.org/
• Public Library of Science (PLoS) Journals: http://www.plos.org/journals/index.php

For drugs

• Drugs@FDA (FDA Approved Drug Products): http://www.accessdata.fda.gov/scripts/cder/drugsatfda/
• Medline Drugs (U.S. National Library of Medicine and the National Institutes of Health): http://www.nlm.nih.gov/medlineplus/druginformation.html   

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