Appealing an Insurance Denial

The denial letter should explain why the claim or request was refused and how to appeal. Common reasons include missing paperwork, a service considered out of network, a treatment labeled experimental or a claim that care is not medically necessary. Note the appeal deadline and where to send it. Ask for a copy of the plan documents and the specific guidelines used to make the decision. Sometimes a denial is caused by a coding error that the provider's billing office can fix quickly without a full appeal.

The first step is usually an internal appeal to the insurance company. Include a letter explaining why the treatment is needed, supported by your doctor's letter of medical necessity. Attach relevant records, such as pathology reports, imaging results and published treatment guidelines. For rare cancers like mesothelioma, a specialist's explanation of why standard options do not fit your case can be especially helpful. Keep copies of everything you send and use a delivery method that provides proof. Ask for an expedited appeal if delay could harm your health.

If the internal appeal fails, many plans allow an external review by an independent organization not connected to the insurer. The insurer's final letter should explain how to request this. State insurance departments often oversee external review for plans they regulate, while some employer plans follow federal rules. Medicare and Medicaid have their own appeal steps. Deadlines matter at every stage, so act quickly. Patient advocates, hospital financial counselors and some nonprofits can help prepare appeals at no cost. Keep treatment going where possible by asking your doctors about temporary alternatives while an appeal is decided.

1. 1

   Read the denial letter and write down the reason, appeal deadline and mailing address.

2. 2

   Ask your oncologist for a letter of medical necessity supporting the requested treatment.

3. 3

   Send the appeal with supporting records using a method that gives proof of delivery.

4. 4

   Request an external review promptly if the internal appeal is denied.