Health Insurance Denials

Does this sound like you? 

I am "fighting" with my HMO. I went to a highly regarded university medical center out of state.  Their new 3-D MRI diagnosed clear artery and vein compressions. I have suffered with 24/7 facial pain, for almost 10 years.  Of course my HMO wants the surgery done here. But I will not let anyone touch me, other than the doctors out of state. This is a redo/MVD. Can you offer any suggestions on dealing with insurance companies who do not want one to go out of area for treatment? I am only 54, and on disability. Am I being discriminated against? Thank you much! Dianne

OR

I live in Florida.  My surgeon was never in my network and neither was my doctor in Seattle, when I had the Gamma Knife.   Due to my persistence and the backing of my Primary Care Physician, the insurance company paid for the services of both doctors, even though they were not in-network.   Cindy

See below for two letters that have been used successfully with one insurance company.  If you have successfully challenged your insurance company to pay for out-of-network treatment, please tell us your story so we can share with others.

Sample letter of appeal to medical insurance company after being turned down to go out of network for a surgical treatment.

Date:

To:             NAME  OR  "TO WHOM  IT MAY CONCERN"

                  INSURANCE COMPANY’S NAME

                  ADDRESS OF INSURANCE COMPANY

From:        YOUR NAME                                                    

                 ADDRESS                                                     ID NUMBER and/or

                 YOUR PHONE NUMBER                               YOUR GROUP NUMBER

Re:          Letter of appeal

I understand and respect your policy concerning “In-network” hospitals and physicians. This however, is not always possible when you are dealing with a rare disorder such as trigeminal neuralgia.

The current physician I am seeing has exhausted all medical therapy for the pain of trigeminal neuralgia.  I am in need of surgical intervention for this very painful disorder.

One of the surgical treatments for the relief of TN is   name of procedure here .

With any procedure for trigeminal neuralgia, the skill and experience of the physician is very important.  Side effects that can occur with these procedures are not only debilitating, but also quite costly to treat.  Therefore we are requesting Dr.________________________ due to his experience with treating trigeminal neuralgia and his skill of this procedure.  Dr.________________________ has privileges at            name of hospital__________.

Please have your neurosurgeon on panel, review this appeal.

I appreciate your immediate attention to this matter. 

Thank you.

Sample letter of appeal to medical insurance company from your primary care physician after being turned down to go out of network for a surgical treatment.

Date: 

To:             NAME  OR  "TO WHOM  IT MAY CONCERN"

                  INSURANCE COMPANY’S NAME

                  ADDRESS OF INSURANCE COMPANY

From:         YOUR PRIMARY CARE PHYSICIAN OR NEUROLOGIST

                   ADDRESS  

                  PHONE NUMBER

RE:             YOUR NAME, ID NUMBER and/or YOUR GROUP NUMBER

I am requesting authorization for my patient,           your name         to be treated and followed by neurosurgeon,         doctor name        , who is not in network.  Dr.        last name       has a special interest in trigeminal neuralgia and has the most experience in this area in treating the disorder.  Due to her/his complicated case and         other mitigating circumstances          , I feel it is in my patient’s best interest that she/he be treated and supervised by Dr.         last name      . 

         your name         is an unusual and difficult case. Briefly her/his history:

Briefly outline her/his medical neuropathic facial pain history.

I have been treating          your name         for _____ years and have exhausted all medical treatments I am familiar with, for this rare disorder. This situation requires close supervision. (If appropriate, include:  She/he has been referred in-network to Dr. name (Neurologist) and  Dr. name (Neurosurgeon) in the past.  They concur that         doctor name         should follow and treat          your name        .

Due to chronic, intractable pain on          your name        , I am requesting authorization for         doctor name         to perform name of surgical procedure.  This procedure will most likely offer her/him the best chance for relief from her/his pain.

As you know, trigeminal neuralgia is a very painful disorder and many things can spontaneously trigger the pain to the point of intolerance. I understand that an authorization number is necessary for referral to a specialist and this is usually obtained in a timely fashion.  I want to avoid any delays that could cause her/him additional suffering  should she/he sustain another intolerable attack.  If further information is needed please do not hesitate to contact me.

Sincerely,

Your primary care physician or neurologist