How To Appeal Denial Of A Referral Or Pre-certification For Treatment
When an insurer denies coverage for a referral to another doctor or for pre-certification for a treatment, the denial rests on the insurer's opinion that what is being suggested is not "medically necessary."
There is no clear cut definition of "medical necessity." Instead, the definition depends on the context and who is making the decision. The basic concept is that medically necessary services are those which are reasonable and necessary or appropriate based on current clinical standards of care.
Build your case for medical necessity by taking the following steps:
- Step 1. Pull our a copy of your insurance policy.
- Each health insurance policy defines medical necessity in wording which is specific for the particular insurer. Locate the description in your insurance policy. Note the page on which it is located and the exact wording of the definition.
- Locate the policy's specific exclusions (treatments etc. which are not covered). Note whether the requested referral or treatment is specifically excluded. If not, note the page number where the exclusions are listed.
- Step 2. Check to determine if either the referral or treatment is required to be covered by the laws in your state. If there is such a mandate, note the citation and the exact wording.
- To learn the law of your state, go to The Actors' Fund Of America's Health Insurance Resource Center (www.ahirc.org , click on your state, then click on "Insurance Guides" and/or Complaints/Appeals). If you have difficulty, contact your Department of Insurance. They can guide you. To locate contact information for your state insurance department, see: www.naic.org . Click on "NAIC States and Jurisdictions."
- Step 3. Put together a brief description of your current health condition. Include a chronology of your symptoms and any tests and treatments you have undergone which relate to the current subject
- Step 4. Obtain a letter from your doctor explaining why the referral or treatment is medically necessary. Ask the doctor to include references which suppport his or her reasoning.
- Step 5. If you can, obtain additional evidence to support your request. For example, letters from other specialists or copies of studies or reports. Work with your doctor and/or his or her head nurse to pull together this information.
- Step 6. Write a letter which includes the above information. We provide a sample letter which you can link to in: Health Insurance: Claims: Appeals: Sample Letter: Not Medically Necessary