It may come as a surprise to you when you receive a letter from your insurance company saying they are not covering your prescribed treatment. This can happen whether this is a treatment you have been on for a long time or a new treatment that your health care provider recently prescribed. Fortunately, there are steps you can take to appeal an insurance decision.
Reasons for Denial
Your insurance company may deny covering your treatment for a variety of reasons.
- Your treatment may not be on your insurance company’s formulary (list of covered treatments).
- The insurance company may not see your treatment as medically necessary.
- The insurance company may want you to try a more affordable treatment first before paying for your prescribed treatment.
Your insurance company should provide you with information in writing with the reasons why your treatment is not being covered. The letter should also include instructions you will need to follow if you choose to appeal the decision.
Steps You Can Take
If you decide to appeal an insurance decision, work with your health care provider who can help to advocate for you. Your provider may need to write a letter to the insurance company explaining why it is important that you get the prescribed treatment.
Your provider should have access to resources designed to help medical professionals write insurance appeal letters, like those offered by the American Academy of Dermatology or by specific drug manufacturers. The Patient Navigation Center can also provide you and your provider with templated letters and resources for appealing a denial.
Explore Other Resources
Depending on your treatment and insurance type, the drug manufacturer may be able to give you a short-term supply of your prescribed treatment while you and your health care provider are appealing the insurance company’s decision.