LymeNet Flash: Does an appeal letter ever appeal to Insurance Company?

This is topic Does an appeal letter ever appeal to Insurance Company? in forum Medical Questions at LymeNet Flash.

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Posted by Pegger (Member # 5621) on :

Hola:
I was recently denied continued coverage for PICC line maintainance (Thanks to the wonderful folks at United Health Care). I'm sure if I bring back enough returnable bottles I'll be able to pay for this frivilous folly. However, just in case...has anyone ever had a doctor write an appeal letter on their behalf...and how did it turn out? Someone advised me that it is really clinical information that they are seeking and would be better received if written by a doctor, not me the lonely bottle collector. Any pointers would be great! Thanks again this is really a teriffic site.

Posted by seibertneurolyme (Member # 6416) on :

Don't know your situation -- are you single or live alone? I maintain hubby's PICC line as all it requires is daily flushing and bandage changes a couple of times a week.

I assume you are asking about having a nurse or health care worker change bandages etc for you.

For other insurance issues hubby has had some success with appeals.

What we have done to save on costs (some doctors charge for medical necessity letters) is to write the letter ourselves and then have the doctor review the letter and sign it. This may or may not work for you depending on your relationship with your doctor.

If the doctor will let you send them a file and then print the letter out on their letterhead that would be great, but it is not absolutely necessary. The doctor's signature is the key issue.

Hubby has had several different appeals and it works better if you can deal with a specific person. You could try calling the appeals dept of your insurance company and see if they will let you talk to anyone by phone or if they will give you the name of someone in the appeals dept.

You should be able to call customer service at your insurance company and request copies of the documentation in your file that details why they denied your claim. By law they must provide this info to you. These records will be needed by you if either you or your doctor writes a letter of medical necessity.

Does your policy have a limit on either number of home health visits or possibly a dollar limit? There has to be some reason your claim is being denied.

There is usually a policy rule that says appeals must be resolved within 60 days or some set amount of time.

Depending on the situation and the amount of money involved most if not all states have insurance commissioners or some such title -- people who are set up to help resolve disputes with insurance companies.
I think this only applies to non ERISA plans -- ones that are not set up through an employer.

Bea Seibert

Good luck.

Bea Seibert

Posted by seibertneurolyme (Member # 6416) on :

Up for more responses.

Posted by Lymetoo (Member # 743) on :

My dr has filed appeals on some drugs for me. It worked.

------------------
Do not take anything I say as medical advice. I am not a doctor, but I DID stay at a Holiday Inn Express!
oops!
Lymetutu

Posted by beach4so (Member # 3832) on :

My oldest son has been the worse affected by lyme. We have had to file appeal after appeal. In the beginning the insurance only paid 25% of a claim.

After appealing with letters from Dr's on medical nessisity he was approved and now they are paid at 50% out of network and 80% in network.

I have had to file 12 appeals on one claim but it is worth it.. keep fighting.

Also keep everything they send you. One appeal said that Lyme was treated in 6 weeks and he did not need extended care.

Another letter came in saying that lyme was a chronic condition and required long term treatment so they wanted us to get with some special perscription plan. I used there own letters against them in a appeal and that is how i won.

Good Luck
Starr

Posted by timaca (Member # 6911) on :

I have had to appeal my insurance company too for my picc line. They have approved 6 weeks so far....but more than that has been ordered for me, so we'll see what they do with the next claim.

You need to respond to why they are denying it...do that say it is "experimental and investigational?" Why are they denying it? Do you not meet their criteria?? You have to answer their questions.

I had to answer laboratory issues..."experimental and envestigational" issues, "exposure to endemic areas" issues, etc.

You can go to the CDC website www.cdc.gov and type in lyme....find info that supports your issues....print it off the computer, and underline your points.

Also www.columbia-lyme.org has some info in the ask the doctor section, and also diagnosis and treatment sections that you can print off and do the same with.

Copy everything you send to your insurance company, and send it FedEx so you are sure that it gets signed for at the other end and doesn't get "lost."

A recent issue of Lyme Times dealt with insurance issues... www.lymetimes.org. You may be able to access that online...it had great info.

Keep at it...the insurance company is hoping you'll give up...it saves them money if you do.

Good luck....God speed....Tina