Appeal

Extended Definition

An appeal is your formal challenge to an insurance decision you disagree with. When insurance denies coverage or payment for a treatment, you have the right to ask them to review that decision.

Types of Appeals

Internal Appeal:

• First level of review
• Same insurance company reviews again
• Different reviewer than original decision
• Usually 30-60 days to file

External Review:

• Independent third party reviews
• Available after internal appeal
• Binding on insurance company
• Available for most denials

Medicare Appeal Process

5 Levels of Medicare Appeals:

1. Redetermination - Medicare contractor reviews
2. Reconsideration - Qualified Independent Contractor
3. ALJ Hearing - Administrative Law Judge
4. Medicare Appeals Council - Further review
5. Federal Court - Final level

Most appeals are resolved at levels 1-2.

Common Reasons for Joint Pain Denials

• Not medically necessary (per insurer)
• Prior authorization not obtained
• Step therapy not followed
• Documentation incomplete
• Experimental treatment
• Out-of-network provider

How to File a Strong Appeal

Include:

1. Copy of denial letter
2. Letter explaining why you disagree
3. Supporting medical records
4. Doctor’s letter of medical necessity
5. Peer-reviewed research (if helpful)
6. Previous treatment documentation

Appeal Success Rates

• Internal appeals: 40-50% success rate
• External reviews: Higher success rates
• Many denials are overturned on appeal
• Don’t give up after first denial

Tips for Successful Appeals

• Meet deadlines - Usually 60-180 days
• Be specific - Address exact reason for denial
• Get help - Ask doctor’s office for assistance
• Keep copies - Document everything
• Follow up - Don’t let appeals languish
• Know your rights - Free assistance often available