What to Do If Your Health Insurance Won't Cover a Specific Treatment

Few experiences are as frustrating as discovering your health insurance won't cover a treatment your doctor recommends.

Whether it's a new medication, specialized therapy, or innovative procedure, insurance denials can leave you feeling helpless and concerned about your health and finances. Fortunately, you have options and strategies to navigate this challenging situation.

Why Your Health Insurance Denied Treatment Coverage

Before taking action, it's important to understand exactly why your insurance company denied coverage. Common reasons include:

Medical Necessity Issues

Your insurer may determine that the treatment isn't required for your condition based on their clinical guidelines. They might claim alternative treatments are adequate or that the requested treatment won't improve your specific condition.

Experimental or Investigational Status

Treatments considered experimental or lacking sufficient evidence of effectiveness are commonly denied. Insurers typically require procedures and medications to have established clinical evidence and FDA approval when applicable.

Network Restrictions

Using out-of-network providers often results in denials or significantly higher costs. Some policies have no out-of-network coverage, while others may cover emergency services but little else.

Prior Authorization Problems

Many treatments require approval before you receive them. If your doctor didn't obtain this pre-approval or if the insurance company determined the treatment didn't meet their criteria, coverage will be denied.

Step Therapy Requirements

Insurance companies often require you to try less expensive alternatives before approving costlier treatments. This "fail first" approach means you must document that standard treatments were ineffective before accessing more advanced options.

Policy Exclusions

Some treatments are specifically excluded from coverage in your policy. Cosmetic procedures, certain fertility treatments, or experimental therapies may be listed as exclusions in your plan documents.

Request a written explanation of the denial from your insurance company if you haven't received one already. This document is crucial for your next steps.

Steps to Take When Treatment Is Denied by Insurance

1. Review Your Policy Documents Thoroughly

Take immediate action by obtaining and carefully reviewing your complete insurance policy. Request your full Evidence of Coverage (EOC) or Summary Plan Description (SPD) if you don't have it. Focus on:

• Sections on covered benefits, exclusions, and limitations
• Appeal procedures, including timeframes and submission requirements
• The definition of "medical necessity" as used by your insurer

Create a document with page references to all relevant policy sections that support your case. Use exact quotes from your policy that demonstrate why your treatment should be covered.

2. Gather Comprehensive Supporting Documentation

Build a compelling case file with complete medical records documenting your condition, including test results, imaging reports, and treatment history.

Obtain a detailed letter from your treating physician explaining your diagnosis and its severity, why the recommended treatment is medically necessary, and why alternative treatments are insufficient for your specific case.

Include peer-reviewed medical literature supporting the treatment's effectiveness for your condition. Document any prior treatments you've tried, including dates, duration, and why they were ineffective.

Ask your doctor to specifically address the reason for denial in their letter. For example, if the treatment was denied as "experimental," have them cite studies and professional guidelines that demonstrate it's an accepted standard of care.

3. File a Strategic Internal Appeal

Prepare a comprehensive appeal package by drafting a clear, concise appeal letter addressing each reason for denial with specific counterpoints. Open with a clear statement requesting approval of the denied treatment and include your policy number, claim number, and date of denial.

Attach all supporting documentation, properly labeled and organized. If time-sensitive, clearly mark as "Urgent Appeal" and include doctor's documentation of medical urgency. Send via certified mail or secure electronic means that provides proof of delivery.

Follow up within 5-7 days to confirm receipt of your appeal and ask when you can expect a decision. Document the name of everyone you speak with and what they tell you.

4. Request a Thorough External Review

If your internal appeal is denied, request an external review within the required timeframe (usually 60-120 days). This review will be conducted by medical professionals not affiliated with your insurance company. For this step:

• Include new information not available during the internal appeal

• Ask your doctor to participate in the external review process if possible

• Follow your state's specific external review procedure

For employer-sponsored plans, work with your benefits administrator to access the external review process. Research your state's external review success rates and average processing times to set reasonable expectations.

5. Explore Comprehensive Alternative Funding Options

While pursuing appeals, actively pursue alternatives:

Patient Assistance Programs (PAPs): Contact the manufacturer of your medication or treatment device directly about both income-based and need-based assistance programs. Check if there are temporary bridge programs while appealing insurance denials.

• Healthcare Advocacy Organizations: Reach out to disease-specific foundations like the American Cancer Society or the National MS Society about specific treatment grants and copayment assistance programs they may offer.
• Hospital Financial Assistance: Meet with a hospital's financial counselor to apply for charity care programs and negotiate direct payment plans with significant discounts.
• Clinical Trials: Consider searching for trials related to your condition that might provide access to treatment at reduced or no cost. Ask your doctor about trials you might qualify for and understand what costs would be covered.

Apply for multiple assistance programs simultaneously to maximize your chances of finding help. Don't wait for one application to be rejected before trying another source.

6. Consider Strategic Legal Options

If appeals are unsuccessful, consider legal avenues to pursue coverage. Schedule a consultation with a healthcare attorney specializing in insurance disputes. File a detailed complaint with your state's insurance department, including all documentation of your case and previous appeals.

For employer-provided insurance, engage your HR benefits specialist and request their advocacy. Many employer plans are self-funded, giving employers more flexibility in coverage decisions.

Consider whether your case might qualify under state or federal insurance regulations, such as mental health parity laws or essential health benefits requirements.

Prepare a one-page summary of your case to share with attorneys during initial consultations. Include timeline, key facts, and copies of denial letters.

Preventing Future Coverage Issues

To minimize future denials, stay in-network whenever possible and check if treatments require prior authorization.

Ask your doctor about coding and documentation that supports medical necessity. During open enrollment, compare plans based on your specific healthcare needs.

When selecting insurance coverage, thoroughly review the formulary (list of covered medications) and treatment coverage details. This is especially important if you have chronic conditions requiring specific treatments or medications.

When to Consider Changing Insurance Plans

If you consistently face coverage issues, take time during open enrollment to compare other available plans. Consider:

• Plans that specifically cover your needed treatments or medications

• Whether a higher premium plan might actually save money by covering necessary care

• Medicare, Medicaid, or Marketplace plans if you qualify

For those with complex medical needs, the lowest premium plan is often not the most economical choice in the long run.

Take into account total out-of-pocket costs, including deductibles, copays, and coinsurance, when making your decision. Remember that plan benefits can change from year to year, so review your options annually, even if you've been satisfied with your current plan.

Advocating for Yourself

Throughout this process, be persistent and organized. Keep detailed records of all communications with your insurance company. Take notes during phone calls, including dates, times, and the names of representatives. Follow up on promises made by insurance representatives.

Don't be intimidated by complex medical or insurance terminology.

Consider working with a patient advocate if the process becomes overwhelming. Many hospitals have patient advocacy departments, and some independent advocates specialize in insurance issues.

Working with Your Healthcare Provider

Your doctor can be your strongest ally in appealing insurance denials. Ask them to write a letter of medical necessity. Request that they participate in peer-to-peer reviews with insurance medical directors.

Discuss alternative treatments that might be covered. Ensure they're using the correct diagnosis and procedure codes.

Sometimes, a simple coding error or missing documentation can lead to a denial that's easily corrected with your provider's help.

Understanding Your Legal Rights

Insurance companies must follow certain regulations. The Affordable Care Act established specific appeal rights. State insurance departments regulate many insurance practices.

Employer-sponsored plans are governed by ERISA (Employee Retirement Income Security Act), and those that separate from their employer generally have COBRA rights, which provide the opportunity to continue health coverage.

Mental health parity laws require equal coverage for mental and physical health conditions.

Knowing which regulations apply to your situation can strengthen your appeal.

Bottom Line

Dealing with insurance denials can be time-consuming and emotionally draining, but many denials are successfully overturned through appeals. Understanding your rights and options empowers you to advocate effectively for the care you need. Remember that healthcare providers, patient advocacy groups, and even your state's insurance department can be valuable allies in your efforts to secure coverage for necessary treatments.

By taking a methodical approach and utilizing all available resources, you can improve your chances of getting the treatment you need while minimizing your out-of-pocket costs. Don't give up after the initial denial—persistence often pays off when dealing with health insurance challenges.

Frequently Asked Questions

How long does the insurance appeal process typically take?

Internal appeals are generally completed within 30 days for non-urgent claims and 72 hours for urgent claims. External reviews typically take 30-60 days, though urgent external reviews may be completed in as little as 72 hours.

Can my doctor bill me for a service if insurance denies coverage?

Yes, you are typically responsible for services not covered by insurance. However, it's worth asking your provider about discounted self-pay rates or payment plans.

What's the difference between a prior authorization denial and a claim denial?

Prior authorization denials occur before you receive treatment, while claim denials happen after you've already received services. Prior authorization denials are often easier to address because you haven't yet incurred the expense.

Can I appeal a denial for a medication that's not on my plan's formulary?

Yes. Many plans have a formulary exception process. Your doctor will need to document why formulary alternatives are ineffective or inappropriate for your specific situation.