- A Claim Denied On The Basis That The Procedure Or Treatment Is Not Medically Necessary
- A Claim Denied On The Basis That The Charges Are Not Usual, Customary and Reasonable ("UCR")
- A Claim Denied On The Basis That The Procedure Is Experimental
- A Claim Denied On The Basis That The Procedure Is Not A Covered Procedure
- A Claim Denied Due To Misrepresentation In The Application
- A Claim Denied On The Basis That The Specialist Or Facility Is Out Of Network
- A Claim Denied On The Basis That The Treatment Or Drug Is Not Likely To Cause Your Health Condition To Improve
- A Claim Denied On The Basis That You Are Likely To Require Care For A Very Long Time
- A Claim Denied For Technical Reasons Such As Incorrect Coding
- A Claim Denied Because You Are Not Home Bound
Arguments To Use Against An Insurer's Denial Of A Health Claim
This document provides arguments to use with respect to each of the following reasons for denying a health claim. Whenever possible, look for information not previously given to the insurer. If there is no new information, at least try to include new evidence to help prove your case.
- The procedure is experimental.
- The procedure or treatment is not "medically necessary."
- The procedure is not a covered procedure.
- The charges are not Usual, Customary and Reasonable ("UCR").
- Misrepresentation in the application.
- The specialist or facility is out of network.
- The treatment or drug is not likely to cause your condition to improve.
- You are likely to require care for a very long time.
- Technical reasons such as incorrect billing.
- You are not home bound.
Do not be surprised if an insurer changes reasons for denying claims as it tries to avoid paying. Confront each reason as it is given. Be persistent. In this case, it pays often enough to be worth the effort.
When appealing a denial, be persistent, be persistent, be persistent. It pays off.
For sample appeal cover letters, see:
- For appeals about Medical Necessity
- For appeals about a request for a Second Opinion
- For appeals about off label uses of medications or experimental treatments
Please share arguments you use successfully either about these reasons or additional reasons for an insurer denying your claim. E mail: dlanday at survivorshipatoz dot org.
NOTE: For a sample cover letter to your doctor about helping with an appeal, click here.