The second in a two-part series on insurance and lumbar artificial disc replacement surgery
After meeting with your doctor, you’re told that you’re a candidate for artificial disc replacement surgery. You and your doctor discuss what surgery entails, and he answers questions regarding your insurance coverage. You learn that your health insurance carrier requires that your doctor submit paperwork for preauthorization prior to performing surgery to determine whether or not they will cover the procedure. Your doctor submits details regarding your diagnosis, why you need artificial disc replacement, and where the surgery will be performed. Your insurance company will perform its clinical review, and within 15 days of your prior authorization request, if they deny you coverage, they must send you a written explanation of their denial. If that happens, what can you do next?
Why They May Have Denied YouAs outlined in our first installment in this series, your health insurance provider likely denied you coverage based on any of the following:
- The surgery is specifically not covered within your policy.
- You have exceeded your benefit level.
- The treatment may be covered, but with restrictions. For example, you may be required to go to a doctor within your insurance provider's physician network. Or, the treatment may be covered, but only for a specific diagnosis.
- Your doctor is recommending treatment that involves new technology that your insurance company considers experimental or investigational.
- Your insurance company has determined the treatment is not medically necessary.
Know Your RightsOnce you determine that you have been denied, your insurance company is required to tell you how you can proceed with an appeal. According the the U.S. Department of Health and Human Services (DHS) website, “You have the right to appeal a health insurance company’s decision to deny payment for a claim or to terminate your health coverage.”
Internal AppealThe DHS recommends that you begin with an internal appeal. These internal appeals are your first request to have your health care claim reconsidered after denial. The health care plan’s in-house clinical reviewers handle this process. To make sure that you put your best foot forward during this process, DHS recommends you do the following:
- Complete all of your health care plan’s required forms.
- Provide all information for reconsideration, including a letter from your doctor.
- If you’re interested in having someone advocate for you, your state’s Consumer Assistance Program can file an appeal on your behalf.
- File your internal appeal within six months of the date that your claim was denied.