This article is the first installment in a series on appealing a denial of cancer treatment coverage.  The second article may be accessed here.

A cancer diagnosis brings with it many challenges, including not just emotional and physical challenges but also financial and logistical hurdles as you attempt to find the best treatment options. Once you receive a cancer diagnosis, the next step is to identify a trusted oncologist with expertise in your type of cancer and the latest and most effective treatment options.  Hopefully this provider will be close to home, but depending on how rare your disease is, you may have to travel to see the top specialists. This can cause problems if the provider is out-of-network. Even if the provider is in-network, your cancer treatment may nonetheless be denied if it is deemed to be “experimental” or not “medically necessary.” This article will address some of the common reasons cancer treatment is denied, and what you can do to protect yourself (and your family) from unforeseen medical bills.

Why Is Coverage for Cancer Treatment Commonly Denied?

A forthcoming blog will address common reasons why cancer treatment may be denied by your insurance company even if your doctor recommends a particular test or treatment as the right one for you.  Grounds for denial may include whether the prescribed treatment is medically necessary, whether proposed treatment is considered experimental or investigational, or whether less intensive or invasive treatments have first been tried without success. Insurance companies have developed written policies and protocols about the standard of care for treatment of particular cancers, but such policies can quickly become outdated.  

Cancer treatment can also be denied or reimbursed at a lower rate if you go to an out-of-network provider unless you can demonstrate that no in-network provider is able to provide the covered service, in which case you may be able to petition your insurer for an exception (though usually this must be done before the services are rendered via a pre-approval process).

Finally, some claims that are related to cancer treatment may be denied as “cosmetic” or “elective” procedures. Examples include breast reconstruction surgery after mastectomy, artificial limbs or prosthetic devices, and cold caps or scalp cooling systems for use during chemotherapy.

What Should You Do If Your Cancer Treatment Claim Is Denied? 

1. Review Your Active Health Insurance Plan

If your cancer treatment claim is denied, your first step should be to request a copy of your health insurance plan from your employer or the insurer to confirm the accuracy of the plan language cited in the denial letter. Health plans change from year to year, and you should never assume that the language quoted in the denial letter is accurate.  If no plan language is quoted in the denial letter, that could be grounds for reversal.

2. Obtain Proof of Medical Necessity

Next, you should share the denial letter with your doctor and ask him or her to write a letter of medical necessity, ideally with citations to the most current relevant medical literature and to National Institutes of Health, Food and Drug Administration, and Medicare guidelines or other private insurer guidelines that demonstrate the service is covered.  There is a good chance your doctor has written such a letter before on behalf of other patients that can be repurposed with little effort. 

3. Expedite the Review of Your Cancer Treatment Claim

In a perfect world, you would also request a copy of your claim file from your health insurer to see what medical and opinion evidence it relied upon to deny your claim. If your health insurance plan is subject to the federal ERISA statute (which applies to most employer-based health insurance), your medical plan is required to provide you with a copy of your claim file. In practice, however, we have found that such requests often go unanswered or take months to process. Thus, waiting for a claim file may not be feasible when time is of the essence.  If there is truly a small window of opportunity for a recommended treatment to be effective, the claim appeal process can be expedited to as short a time period as three days.

If the amount of money in issue is large enough, you should consider hiring an attorney to assist you with preparing the appeal.  An attorney can spot issues, identify ambiguities in plan language, and cite relevant case law to maximize your chance of success on appeal.

4. Appeal the Denied Claim

Submit your appeal letter, including the letter of medical necessity from your treating doctor, and any medical journal articles and coverage guidelines you want the plan to consider, before the deadline specified on the denial letter, preferably both by certified mail and fax.  If you are appealing the denial of a pre-approval request, and the requested treatment is urgent, you can and should request expedited review.

5. Consider Independent External Review

A major feature of the Affordable Care Act (Obamacare) is a requirement that most health insurance denials are eligible for independent external review which is managed by each state’s Department of Insurance.  When the appeal rights set forth in the policy are exhausted, the insurance company is obligated to advise claimants of their right to request independent review.  The review will be performed by a specialist physician who is selected by the Department of Insurance rather than by the insurance company.  That doctor is provided with all of the underlying claim documentation and is expected to render an independent determination that is consistent with generally accepted standards of medical care and treatment.  If your treating doctor is adamant that the insurance company’s determination is flat-out wrong and can point to comprehensive peer-reviewed studies that contradict the position taken by the insurance company, the independent review may be the route to a speedy resolution of the claim.

6. Consider Litigation

If your appeal is denied, you have the right to request external review by a doctor not affiliated with your health plan. Be advised, though, that if your external request is unsuccessful, it could be cited by your health plan in subsequent litigation. Thus, if litigation is contemplated, it’s best to discuss your options with an attorney prior to requesting external review.

If all else fails, consider switching your health insurance plan. You may be eligible to join your spouse’s health insurance plan, or you can enroll in an individual policy of health insurance through www.healthcare.gov. You may also qualify for Medicare after 29 months if you are not working and are deemed disabled by the Social Security Administration.

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