Successful Appeals
Appeals are more likely to go in your favor if they:
- Contain easy-to-prove facts
- Are to the point and only contain necessary information
- Are complete
- Are submitted within the time allowed by your plan
- Show you were active and persistent in your interactions with your health plan and your doctor
Ideas for appealing different types of denials
Medically Unnecessary
- Have your doctor (and possibly other medical experts) provide written documentation to explain why the prescribed treatment is medically necessary
Experimental
Your health plan may cover treatment ruled as experimental if you can prove it is one of the following: Your health plan may cover treatment ruled as experimental if you can prove it is one of the following:
- Medically necessary
- The only treatment that will work (document what hasn't worked before)
- Less expensive than the "standard" treatment
- Considered "standard" treatment by the medical community
- A treatment your health plan has paid for in the past for people who have the same medical condition as you
Network
If your claim was denied because the doctor was out-of-network, you'll have a greater chance to win your appeal if you can prove the plan's network had:
- No providers with the specialty you needed
- Very long wait times for the in-network providers
- No providers in your surrounding area
Mistake by your plan
- Prove you or your medical provider followed the rules under your health plan.
- Prove the denied treatment falls within a gray area within the plan's covered services. If it's not explicitly excluded, you could reason your plan should pay for it.
If all else fails, sometimes just asking your health plan for an exception can help your case!
