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Sample Appeal Letter for Services Denied as 'Not a Covered Benefit'

As someone with cancer or a caregiver for someone with cancer, you have a lot on your mind without having to worry about payments and insurance. Unfortunately, some insurance companies may reject claims for certain health services. You do have the option to appeal, however.

In fact, under the Affordable Care Act (ACA), when treatment is denied, you have the legal right to ask for an internal review and, if this appeal is denied, an independent, external review.  This right applies to plans created after March 23, 2010.

In addition, for plan years or policy years purchased on or after July 1, 2011, the insurance company must inform you of why your claim was denied, your right to an internal appeal, your right to an external appeal if the internal review denies your claim, and the availability of a Consumer Assistance Program (CAP) if your state has one. 

  • To see if your state has a CAP, go to Consumer Health at: http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html.  

Internal reviews must also occur within specific timelines.  A review for the denial of  non-urgent care that you have not yet  received for example, must occur within 30 days of your review request..  

You can use this letter as a model for an efficient, effective appeal letter. You may also need to enlist the help of a legal professional. Make sure your doctor knows any issues you have with insurance, as he or she may be able to help you.

[Letter should be addressed to the name of the Appeals Analyst referenced in the Denial Letter. It should be sent certified mail, return receipt requested. If you are requesting an expedited review, it should also be faxed or hand-delivered.]

Dear [Appeals Analyst]:

I am writing, on behalf of [name of Plan member if other than yourself], to appeal the [name of Health Plan] decision to deny [name of service, procedure, or treatment sought] for [name of Plan member if other than yourself].

It is our understanding that [name of Health Plan] is denying coverage on the basis that "[cite Health Plan’s language in the denial letter]." [Attach denial letter.] We believe that [name of service, procedure, or treatment sought] is medically necessary to treat [name of Plan member if other than yourself]’s medical condition and that [name of service, procedure, or treatment sought] is a covered plan benefit.

[Name of Health Plan] covers medically necessary services that are not expressly excluded, which are described in the Evidence of Coverage and which are authorized by the member’s PCP and in some cases approved by an Authorized Reviewer. [Attach relevant section from Evidence of Coverage.]

The entire treatment team has recommended that [name of service, procedure, or treatment sought] is medically necessary. [Attach supporting medical letter.]

Contrary to your letter, [name of service, procedure, or treatment sought] is a covered service. [Name of service, procedure, or treatment sought] is stated as a covered benefit in your HMO Member Handbook, is implicitly covered in the Evidence of Coverage, and is not expressly excluded as a covered service in the Evidence of Coverage. [Quote from Member Handbook and Evidence of Coverage to establish that the service, procedure, or treatment is a covered benefit and not expressly excluded.] [Cite your state’s mandated benefit laws requiring that the health plan provide this coverage.]

[Describe member’s health condition, and why the service, procedure, or treatment would benefit the member and the consequences if the patient does not receive this treatment.]

[If the treatment is out-of-network, establish that there are no comparable services offered within the network.]

[Finally, if you feel they won’t cover the service because of the precedent, ask them to consider covering it as an extra-contractual benefit, and to pay for the service, procedure, or treatment out of the Health Plan’s catastrophic payment pool.]

[If the member requires immediate treatment for the condition, request an expedited hearing – request that they respond within 72 hours of mailing of the letter. Note that ACA now requires a 72-hour  expedited internal review for urgent care. This time frame is required for plan years or policy years beginning on July 1, 2012.]

[Attach a letter from your treating physician describing the patient’s condition.]

Thank you for your immediate attention to this matter.

Sincerely,

[Your name]

cc: [Possible individuals to whom you should consider sending copies of your letter]

[Health Plan Medical Director]

[Medical Group Medical Director]

[Your primary care or treating physician]

[Your state representative if you anticipate further denials]

 

For more information on the ACA's Right to Appeal process, please go to:  http://www.healthcare.gov/law/features/rights/appealing-decisions/index.html.

 

Online Medical Reviewer: Fincannon, Joy, RN, MN
Online Medical Reviewer: MMI board-certified, academically affiliated clinician
Last Review Date: 2/3/2014
© 2013 Krames StayWell, 780 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare provider's instructions.