Health Insurance: Denials and Appeals:

Are you facing a health insurance claim denial? Or are you about to receive a medical service that you have reason to believe will be denied by your health insurance provider? Below are online references that might help to either overturn a denial of a claim or prevent the denial of a claim. These web pages are organized in two ways: 1) by the reason for the denial of the health insurance claim and 2) by the condition for which the medical service is needed or treatment that is denied. General resources follow at the end of this page.

Reasons for Denials:

Habilitative services are covered. Rehabilitative services are not covered.

Speechville (childhood speech/language/communication disorder)

Treatment is experimental. Experimental treatments are not covered.

• Artificial disc replacement / insurance denial as "experimental"

• Chhelp.org (cluster headache)

• Insurance Denial Of Avastin (Chemotherapy Drug for Cancer Treatment)

Treatment was performed by out-of-network provider

• Emergency treatment - out-of-network hospital

Condition for which treatment is prescribed is not a covered benefit (or condition is not an illness or injury), therefore treatment for condition is not medically necessary.

• Speechville (childhood speech/language/communication disorder)

• Chhelp.org (cluster headache)

• Letter of Medical Necessity (lymphedema)

• Sample Physician's Statement of Medical Necessity (Pulmonary Hypertension)

• Samples of Letters of Medical Necessity

  • Create A Custom Sample Letter

  • Amyotrophic Lateral Sclerosis (1st)

  • Amyotrophic Lateral Sclerosis (2nd)

  • Congenital Muscular Dystrophy

  • Duchenne Muscular Dystrophy (1st)

  • Duchenne Muscular Dystrophy (2nd)

  • Myotonic Muscular Dystrophy

  • Spinal Muscular Atrophy Type 1

General advice and sample appeal letter - written by mother of child with complex medical issues

Insurance Information for Specific Conditions or Treatments:

Adrenoleukodystrophy	Tips to effectively battle your insurance company
Attention Deficit Disorder	ADD prescription for Concerta not fully covered
Autism	Autism & Insurance: Appealing Insurance Denials Parents Helping Parents: Has Your Health Insurance Rejected Your Claims for Autism Services? How to Get Your Child's Autism Treatments Covered by Health Insurance
Bariatric Surgery	Bariatric Surgery Discussion Board: Insurance Denial Sample Patient Appeal Letter for Bariatric Surgery
Bone Marrow Transplant	Insurance Denial of Bone Marrow Transplant (BMT)
Breast Cancer	What to Do if a Claim Is Denied Experimental Breast Cancer Treatments and Health Insurance Coverage Breast Cancer Health Insurance: Successfully Handling Claims, Denials and Appeals
Cancer	Insurance Denial Of Avastin (Chemotherapy Drug for Cancer Treatment) Ovarian Cancer National Alliance: Insurance Denial Sample Letter to Insurance Co. After Denial of PET Scan (gastrointestinal stromal tumor or GIST) Medical care's state of denial (features patients with bile-duct cancer and colon cancer) Cancer in Children: Legal Issues and Insurance Coverage Pushing Back on Insurance Coverage Denials Including Proton Therapy Patient Insurance Strategies (Proton Therapy) Health Insurance and Financial Assistance for the Cancer Patient
Celiac Disease	Insurance Company Documents Show Celiac Disease is an Automatic Denial for Health Coverage
Cleft Lip/Palate	Sample Denial Letters (Cleft lip and/or palate ie, orofacial clefts)
Cluster Headache	Chhelp.org
Cochlear Implantation	HealthNot Insurance Denial (cochlear implantation)
Communication Disorders including Apraxia, Articulation Disorder, Late Talking, Phonological Disorder, Speech Delay	Insurance Denials based on Childhood Communication Disorders
Deafness	Denied for Health Insurance Due to Deafness
Diabetes	Diabetes-related medical equipment Continuous Glucose Monitoring Anti-Denial Campaign
Disc Replacement	Artificial disc replacement / insurance denial as "experimental"
Duodenal Switch Procedure	Insurance Issues
Durable Medical Equipment	The Insurance Appeal Process
Emergency	Septic Infection
Fibromyalgia	Insurance Company Denial of Lyrica for FMS Treatment
Gallbladder Surgery	Gallbladder surgery
Gastroesophageal Reflux	Restricting Insurance Coverage for Children with GERD
Gastric Bypass Surgery	Has anyone fought Medicaid insurance denial: gastric bypass surgery
Growth Hormone Replacement Therapy	Mini Primer on How to Handle an Appeal of Denial of Insurance Coverage for Growth Hormone Replacement Therapy
Gynecomastia	Gynecomastia Insurance Denial
HIV	HIV Guide: Insurance Denial of Interleukin
Hypertrophic Cardiomyopathy	Insurance Denial of Echo (Hypertrophic Cardiomyopathy) Hypertrophic Cardiomyopathy: Insurance Denial (based on code used)
Infertility	State Insurance Infertility Laws Insurance Coverage for Infertility Treatment
Lap Band Surgery	Insurance Coverage for Lap Band Surgery Lap Band Surgery - Tips for an Appeal Lap Band replaced with VSG
Lymphedema/Lymphodema	How to File A Health Insurance Appeal Sample Insurance Appeal Letter
Maternity/Pregnancy	Maternity coverage
Miscarriage	Blue Cross Blue Shield Calls Miscarriage "Elective Abortion," Denies Claim
Muscular Dystrophy	Congenital Muscular Dystrophy Duchenne Muscular Dystrophy (1st) Duchenne Muscular Dystrophy (2nd) Myotonic Muscular Dystrophy
Multiple Sclerosis	Insurance denial for electric lifts (Multiple Sclerosis) Appealing a Coverage Denial or Limitation by Your Health Plan Sample appeal letters (coverage of Avonex , Betaseron, Copaxone, Rebif, Novantrone, IntraVenous ImmunoGlobulin, Neurontin, physical rehabilitation/therapy, Provigil, sterile intermittent catheterization)
Neurofibromatosis	Dealing with the Denial of Treatment by Insurance Company (neurofibromatosis) Making the Most of Health Insurance
Obesity	Obesity Action Coalition: Appealing a Denial Appeal letter re denial for weight loss treatments and medications
Plagiocephaly	Insurance coverage denial leads to class action suit: Plagiocephaly
Plastic Surgery	Tummy Tuck Plastic surgeries that are often reimbursed by insurance Successful Sample Appeal Letter to Obtain Insurance Coverage for Plastic Surgery After Rapid Weightloss
Podiatry	Tips: CPT-ICD-9 Codes, Physical Therapy, X-Rays , Durable Medical Equipment (DME), Surgery , Routine Foot Care, E/M Coding, Casting
Proton Therapy	Pushing Back on Insurance Coverage Denials Including Proton Therapy Patient Insurance Strategies (Proton Therapy)
Pulmonary Hypertension	A Guide to Understanding Your Healthcare Insurance Benefits: Appeals Tips to Successful Communication with your Insurance Company Glossary of Terminology Sample Letters Sample Physician's Statement of Medical Necessity
Scoliosis	Scoliosis
Sudden Arrhythmia Death Syndrome	Health Insurance Tips & Resources
Vascular Anomalies	Health Insurance Coverage for Vascular Anomalies: How to Appeal a Denial of Benefits
Wheelchairs, scooters	Insurance coverage for wheel chair for disabled person Electric scooter appeal

Resources by State:

State by state outline of patients' rights to external reviews when an insurance claim has been denied (by the Kaiser Family Foundation):

ARIZONA:

• A Consumers Guide to Group Health Insurance in Arizona

• A Consumers Guide to Individual Health Insurance in Arizona

CALIFORNIA:

• Los Angeles County Medical Association: Patient Resources: Insurance Company Complaints

COLORADO:

• Colorado General Assembly: Digest of Bills - 1997: Insurance

FLORIDA:

• Florida Insurance Council: Denial of Claim: What to do if a Health Insurance Company Denies Your Claim

IDAHO:

• Idaho Health Carrier External Review Act

ILLINOIS:

• Illinois Department of Insurance: What to Do if a Health Insurance Company Denies Your Claim

MAINE:

• Guide to Requesting an Independent External Review for Health Insurance

MARYLAND:

• State of Maryland Bulletin: Denial of Coverage Based on Medical Necessity: Internal Grievance Process

• Maryland Attorney General: When Your Health Plan Says 'No'

MICHIGAN:

• External Review Procedure for Health Insurance and Health Maintenance Organization (HMO) Complaints

• Michigan's Health Insurance Independent Review At Two Years

MINNESOTA:

• Health Insurance External Review Appeal

NEW YORK:

• New York State: Insurance Help for the Seriously Ill and their Caregivers: If Your Request is Denied

• HMO and Health Insurance Tips for New York State Consumers

• N.Y. Consumers to Get Better Explanations When Coverage Denied
  

OHIO:

• Ohio Legal Rights Service: What About Health Insurance?

OREGON:

• How do my medical bills get paid?

TEXAS:

• Texas Department of State Health Services: Children with Special Health Care Needs Services Program
  

UTAH:

• Utah Insurance Department: Health Insurance: What to do if a Health Insurance Company Denies Your Claim

VERMONT:

• Division of Health Care Administration: Health Insurance: Your Consumer Rights

VIRGINIA:

• Commonwealth of Virginia, State Corporation Commission: Tips to Help You Appeal a Prescription Medication Denial with Your Managed Care Health Insurance Plan

General information about appealing insurance denials can be found at the following sites:

When an Insurance Company Breaches Its Contract

Making a Killing (See: Appendix One - HMO Patient Self-Defense Kit)

General Insurance Law Questions

If the insurance denial you have received seems erroneous, see the following information about "bad faith" as it applies to insurance law:

Fight Bad Faith Insurance Companies

Also See Books: Insurance: Consumers