You likely have the right to access records that explain why your insurer denied your claim or prior authorization request. Use ProPublica’s free tool to generate a letter requesting your claim file from your health insurance company.
I’ll spoil this for you, much of the time they didn’t even read the medical documentation sent to them, just denied whatever was asked for. And then hoped the patient would drop it and never even let their doctor know it was denied. Or if that fails and the doctor finds out it was denied they hope the busy doctor wouldn’t be able to figure out how to contact the company and the right number to do so, navigate phone trees and find archaic long series of ID numbers and case numbers and other information specific to that one company, then schedule a time range of hours, often in the evening at home, to be ready to answer a call at any moment from some “peer” (who’s not actually a peer, a doctor, or even in the same specialty) who also never read the medical documentation sent. The doctor points out to the company the rationale meeting all their criteria is clearly met in the medical documentation. But the “peer” states their company has a new additional rule about that treatment and that wasn’t included in the initial documentation sent. The doctor points out it was, the “peer” claims they don’t have it though. This is followed by another denial. That additional documentation is sent in again, no response for weeks (please allow up to 4 weeks for response). After finally getting a hold of someone, they state that they can’t accept this since there was already a denial and now must go through an official appeal hoping the doctor won’t know how to find out about their seperate and distinct appeal process. If the doctor figures out how to do that then they hand write a letter again explaining the medical rationale for the treatment being denied including citing sources from the literature. But oh wait that appeal was denied, because this was a Medicare advantage plan or some crap and the appeals process used is not applicable to this plan type. But you may file an appeal with the state insurance authority. And it goes on.
Anyways, three months and much unpaid labor later, treatment finally approved. Which, if they had just read the original note sent, should have been approved in the first place. Not speaking from experience here or anything, lol.
I’ll spoil this for you, much of the time they didn’t even read the medical documentation sent to them, just denied whatever was asked for. And then hoped the patient would drop it and never even let their doctor know it was denied. Or if that fails and the doctor finds out it was denied they hope the busy doctor wouldn’t be able to figure out how to contact the company and the right number to do so, navigate phone trees and find archaic long series of ID numbers and case numbers and other information specific to that one company, then schedule a time range of hours, often in the evening at home, to be ready to answer a call at any moment from some “peer” (who’s not actually a peer, a doctor, or even in the same specialty) who also never read the medical documentation sent. The doctor points out to the company the rationale meeting all their criteria is clearly met in the medical documentation. But the “peer” states their company has a new additional rule about that treatment and that wasn’t included in the initial documentation sent. The doctor points out it was, the “peer” claims they don’t have it though. This is followed by another denial. That additional documentation is sent in again, no response for weeks (please allow up to 4 weeks for response). After finally getting a hold of someone, they state that they can’t accept this since there was already a denial and now must go through an official appeal hoping the doctor won’t know how to find out about their seperate and distinct appeal process. If the doctor figures out how to do that then they hand write a letter again explaining the medical rationale for the treatment being denied including citing sources from the literature. But oh wait that appeal was denied, because this was a Medicare advantage plan or some crap and the appeals process used is not applicable to this plan type. But you may file an appeal with the state insurance authority. And it goes on.
Anyways, three months and much unpaid labor later, treatment finally approved. Which, if they had just read the original note sent, should have been approved in the first place. Not speaking from experience here or anything, lol.