You’ve been denied coverage, or the level of coverage you received was too low based on your insurance policy documents. You’ve checked the Explanation of Benefits (EOB): there were no obvious errors. You called the insurance company and were not satisfied with the outcome of that call. What next?

If you feel that a claim was erroneously denied, you can stage an appeal, a formal request for reconsideration based on information that you, or your doctor, will supply. This information can come in many forms, and from many sources. The information should be summed up in a document called a Letter of Medical Necessity (LMN).

The first step is always seeing if your doctor’s office will handle the appeal for you. Some will, some won’t. If they will – perfect!

Sending a prepared Letter of Medical Necessity. If you are sending an LMN that was prepared by your doctor’s office, make sure to enclose a short cover letter identifying the claim. Include the patient’s name, the name and ID number of the insured party, group number (if applicable), item requested and claim number if one has been assigned. An example cover letter:

Dear Mr./Ms. (Name):

In response to Your Insurance Company’s denial of 4/8/05 (please see attached), regarding the following claim:

Patient: Jane Public
Insured: John Q. Public (father)
Insured ID: 123-45-6789
Group #: 12345
Item: Wheelchair (be specific – include the make and model name/number)
Claim number: 98765

I am enclosing the requested letter of medical necessity from Dr. Smith, MD, of the Orthopedic Medicine Department of (hospital name). Please contact me immediately at (512) 555-1234 if further information is required.

Thank you.

Sincerely,

If your doctor’s office is unwilling or unable to find the time to do the research and write the LMN for you, you will need to do the work yourself. See if your doctor will be willing to sign a prepared Letter of Medical Necessity. If he/she will, you will need to write the letter from the doctor's point of view. Avoid phrases like "my daughter" or "my son" or anything else that identifies you as the author of the letter. If the doctor has not agreed to sign the letter, you can write it from your point of view and sign it yourself. Either way, the letter will need to explain why the item or therapy you are requesting is medically necessary for your child.

Writing an appeal letter on your own. Some appeals will be simple. You’d be surprised at some of the seemingly silly – and easily fixable - things that an insurance company will deny a claim over. Other appeals will be harder. For example, proving that an item is medically necessary takes research, time and energy. Whether you take on the challenge of an appeal by yourself or you seek help with the appeal, you will need to know the proper process and follow it exactly. Before you expend any energy on the appeal, call your case manager and make sure you understand the precise reason for the denial and what you need to provide to get the appeal processed and approved.

Try not to think of this as a hassle – treat it as an opportunity to educate your case manager and the insurance company about your child’s condition, and the various therapies and equipment that your child needs. The effort you make now may prevent another family from having to repeat the process later. This attitude shift might seem impossible to make, but it will help you keep your cool while you’re dealing with the company, and that is important. Facts and reason will win an appeal. Emotion will not.

One FighterMom says: The most ineffective thing you can do is try to appeal to their emotions - the person you spoke to can't very well go to their superiors and say "well, I had to give it to her - she cried.”

Here are some basic steps to follow:

a) Before you can begin the appeals process, you need to determine exactly why your claim was denied. If you have not already done so, call your case manager for more detailed information about the denial. Have the EOB in front of you when you call and take down the exact reason for the denial.

b) Gather as much information about the original claim as you can. If your doctor’s office provided the insurance company with a Letter of Medical Necessity (LMN) stating his/her exact reasoning for prescribing the equipment or therapy, try to get a copy. Knowing what the insurance company was already told can be helpful. If a formal LMN was not prepared, get the diagnosis code (also called an ICD-9 code) that was used to justify the application. Make sure that the item was coded correctly – if a single digit of this code is wrong, it may explain why the item was denied. If the ICD-9 code is wrong, call your doctor’s office immediately and have them revise the claim.

c) Do research. Visit the manufacturer’s website first. Many times their website will contain links to supportive journal articles; use these articles to persuade your insurance company to pay for the item. Search online medical journals for information about the item or procedure you are trying to get approved. If you don’t have Internet access, contact the manufacturer by phone. They are usually very helpful because, if insurance doesn’t cover their product, chances are it won’t sell at all. Try to find other families who have had the item approved and find out how they got it; you may be able to use another family’s LMN as the basis for yours.

Manufacturer’s guidelines, articles from medical journals, current research abstracts and detailed information about your child’s particular case are all good pieces of information to use to support your request

d) Write the letter. This is a serious situation and merits a serious tone. Be as straightforward and businesslike as you can. Make sure to include all of the information about the original claim as possible – patient name, insured’s name (this sometimes differs from the patient name – check the EOB to be sure), insured’s ID number, date of claim, etc. If you have a case manager, address the letter directly to them and make sure to mail it to them directly. Write out all of your reasons why their denial was incorrect, but stick to the subject. If they denied a piece of equipment because it is not medically necessary, for example, make sure that by the end of your letter, you have given several pieces of proof that the equipment is a generally accepted form of treatment for your child’s particular condition. It is also a good idea to point out what’s in it for them. Explaining to them that spending $1,000 on a preventative treatment now will save them $10,000 in hospital costs down the line may help. Remember, insurance companies are in business for one reason and one reason only: to make money. Because what they do is so sensitive, we tend to forget that. It's nothing personal, but it can feel that way sometimes. Just keep it impersonal - stick to the facts - and they will have a harder time rejecting your appeal.

Avoid using reasons that do not directly relate to the health and well being of your child. Many reasons that are valid from a moral, even a logical standpoint, such as avoiding caretaker injury from lifting your child or caretaker’s need for sleep do not generally have an effect on an insurance appeal and, in most cases, are specifically excluded from consideration by insurance policy documents.

e) Back it up with copies of supporting articles. If you are unable to provide actual copies of the articles that you are citing, provide enough information about the article so that your case manager can find the article for him/herself. A proper citation includes a list of authors, article title, journal name, journal issue, and page numbers.

f) Use their own words against them. Comb through your policy documents for anything that supports your claim. If you do not have your policy documents, try the company’s website. If your primary insurance is Medicaid or other state-funded insurance, try the homepage of the division of state government that administers the program (the name of this department varies from state to state).

g) If the insurance company sent a formal letter of denial, it wouldn't hurt to attach a copy of that as well. The less work the insurance company has to do, the quicker you'll get an answer. It helps to remember that there is a human being on the receiving end of your letter. Think "what else can I do to make their job easier." It won't hurt to help them out by providing all the info they need and prevent them having to dig through files to find information.

An example LMN format:

Date

To Whom It May Concern: (or, if you have a case manager, address it to them directly)

I am writing on behalf of my daughter, Jane A. Public, regarding An Insurance Company’s denial of claim number 456 on 07/06/2006. A copy of the denial is attached for your convenience.

The basis of this denial was that Pediatric Vivonex is considered a dietary supplement and is therefore not covered on our plan. However, in Jane’s case, Vivonex is a source food, not simply a supplement to a normal diet.

Jane suffers from Spinal Muscular Atrophy (SMA), a disorder of muscle and of fatty acid metabolism that requires a special diet to maintain optimal health. In addition to metabolic aberration associated with immobility, systemic illness, muscle denervation, and muscle atrophy, SMA patients have inborn metabolic abnormalities in mitochondrial fatty acid oxidation and carnitine metabolism that may increase the liver and kidney's production and excretion of dicarboxylic acids.

Harpey et al. felt that there was a significant improvement in strength and function for 13 patients treated with modified diets that provide high carbohydrate and elemental amino acids and small-chained polypeptides, such as Tolerex and Pediatric Vivonex (Novartis, Minneapolis). (1)

In light of the above evidence that Pediatric Vivonex will be used as a source food and not merely as supplemental nutrition in Jane’s case, I am requesting a review of this claim. Thank you for your consideration of this matter.

Sincerely,

John Q. Public

Member name: John Q. Public
Member# 123-45-6789
Group# 987654321

(1) Harpey JP, Charpentier C, Paturneau-Jonas M, Renault F Romero N, Fardeau M. Secondary metabolic defects in spinal muscular atrophy type II. Lancet 1990; 336: 629-630

Uncooperative doctor and no time to handle it alone? If taking care of your child does not allow you the time to do the research required to handle an appeal on your own, and your doctor’s office is not being helpful, there is other help available. I have been providing free, no-obligation insurance claim assistance to SMA families for nearly four years and have recently expanded my work to include the Fighter Mom community. If you have questions, simply reply to this journal entry or email me at kpax@charter.net. Please remember that I do this work on a volunteer basis, so I may not be available immediately, but I will get back to you as soon as possible.