Insurance for ADR: The Denial & Appeal Process
Part 2 in a three-part series on insurance and lumbar artificial disc replacement surgery
- Once your doctor submits the pre-authorization documents to your health insurance provider, the provide has 15 days to respond.
- If denied coverage for your surgery, you and your doctor can begin the appeal process with your health insurance provider.
- Your insurance provider has 30 days to respond to your appeal. If they deny you again, you have the right to an external review.
- External reviews take up to 60 days and are conducted by outside surgeons who turn their finding over to your health insurance provider who can then accept or reject the review.
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 You
As 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, or your insurance company has determined the treatment is not medically necessary.
- Your insurance company has determined the treatment is not medically necessary, or it does not have therapeutic benefits.
- Your insurance company deems the recommended treatment option to be experimental. This can be the case for procedures that involves new technology.
Before launching into an appeal process, fully understand why you were denied. If your claim was denied because your insurance company needs additional information, you may not need to appeal. You may simply need to gather the necessary information and re-submit according to the company's policies and procedures. This happens, for example, with a typical requirement that you have six months of conservative treatment prior to any low back pain surgery.
Know Your Rights
Once 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.”
The 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.
Once you file your internal appeal, your health insurance provider has 30 days to complete its review. Again, you’ll receive a written decision and, if you’re again denied coverage, you can ask for an “external review.” By law, your health insurance provider must tell you the steps required to pursue an external review.
The next step in the appeal process is an external review. An external review is your right to have the requested service evaluated by an independent third-party physician who specializes in the area pertaining to the case, which, in the case of lumbar artificial disc would be an orthopedic or neurosurgeon. External reviews are effective because they place pressure on health insurance companies to re-evaluate coverage policies in light of compelling data pertaining to the procedure. At the end of this appeal, a final decision will be rendered by which an external review either upholds your health care plan’s final decision or their denial is overturned and coverage is decided in your favor. If the latter scenario occurs, your insurer is legally obligated to accept the external reviewer’s decision. Expect the eternal review process to take up to 60 days. While these are general guidelines to follow, be sure to investigate and learn the complete guidelines that govern your state. Any questions or assistance needed to file an appeal should be addressed by your state’s Consumer Assistance Program or Department of Insurance.
If your provider still chooses not to cover your surgery following an external review, you may be forced to litigate. In part 3, we'll discuss how to move from proof to coverage.