YOUR VOICE MATTERS: How to Navigate an Insurance Appeal

Claim Denied

By Denise Hoffman

There are many challenges members of the limb loss and limb difference community face every day. One of the greatest challenges is overturning an insurance denial for assistive devices. Here are some helpful tools to put in your toolbox when a denial occurs.

Know your insurance plan

  • Even if it says it doesn’t cover prosthetics or your specific assistive device, overturning a denial is possible.
  • Statement of Benefits
  • What does your plan cover?
  • What does your plan exclude?
  • What are your out-of-pocket costs going to be?
  • Which providers are considered In-Network, and which providers are Out-of-Network?

Insurance Denials

  • Many insurance companies are required to deny a certain number of claims upfront, regardless of the policy coverage.
  • If you have an employer-sponsored plan, you can work with HR to understand your options.
  • It’s important to work with your medical team in the appeals process if you are denied coverage.
  • Know how to write a compelling appeal letter (with your medical team or on your own).
  • Follow up on your appeal.
  • Be aware of insurance fairness laws and coverage requirements and applicability in your state.

Steps of a denial

If your claim is denied, then you should file an appeal. You then will receive a finding. If denied again, there may be a need for a secondary appeal. If your claim is denied again, you can elevate it to your state insurance commissioner if you still feel the determination was incorrect.

Work with Human Resources

How do you work with HR? Pre‑emptively (before employer chooses new plans and renewals), make them aware of your assistive device needs and request they consider plans that have good coverage of the device you require. Within your current coverage limitations, HR can help you navigate your current plan, and/or even help you with the appeals process.

Work with your medical team

Communicate your needs, lifestyle, activity level, goals, work, and hobbies with your prosthetist or surgeon, primary care physician, physical/occupational therapist, and/or physiatrist. Their assessments and thorough documentation of the above details are crucial in the appeals process.

How to write an appeal letter

Include your name, insurance plan number, and reason for denial. Be polite and courteous, using please and thank you. Explain your activities of daily living (using stairs in the home, walking up ramps in driveway, taking care of small children, etc.). Also, explain your work environment and the necessity of certain functions you need the assistive device to perform. Explain the hardships that occur every day without the appropriate assistive device you need and ask for a timely approval of your device. Make it personal, providing as much detail of your daily life and activities as possible. Including photos, and/or videos of the above can also help personalize your story. You can also include research and documentation outlining the benefits of the assistive device you are requesting. Consult your prosthetist, medical providers, and the Amputee Coalition for available documentation that supports coverage of your device. If requesting coverage of a prosthetic device, know what your insurance company covers for a knee, hip, ankle or shoulder replacement surgery. Request that you’d like the same coverage for your external prosthetic device that is provided for internal prosthetic devices. Keep a copy of your letter and documents. Mail all your documentation in a certified letter to your insurance claims department, so that you have a record of when they have received your letter.

Follow Up

If neither you, nor your prosthetist or medical provider, have heard back from your insurance company within a timely fashion, contact your insurance company and ask to speak with a patient advocate, or your case manager. Have a copy of your letter and documentation available. Ask if there has been a review of your appeal. If it has not yet been reviewed, then ask when you can expect a response or when you can follow up again. If it has, then ask if there is any other documentation needed, or anything else that you can do to help facilitate the approval. You can reiterate your activities of daily living, your necessity to return to work, the benefits of having this specific device, and the daily hardships that you encounter without your device (or with an aging or antiquated device). Again, ask that your prosthetic device be considered for the same coverage as internal prosthetic devices like a knee or hip replacement.

Insurance Fairness for Amputees Act

Determine if your state has the Insurance Fairness Act in place. Find your state policy at www.amputee-coalition.org/advocacy-awareness/state-issues/. Also, determine if your insurance company is regulated by your state’s insurance laws. Self-funded plans are regulated at the federal level and private and small group plans are regulated under the state level. You can call your Human Resources office, or the local office managing your insurance plan, to determine the regulation of your insurance company.

Once these two steps have been verified proceed with

  1. Sending a copy of your state’s insurance fairness law to your health plan administrator.
  2. Contact your state insurance commissioner to alert them to enforce this issue at www.naic.org/state_web_map.htm.
  3. You can also consider seeking assistance from your state’s consumer protection office if your insurance company isn’t complying with the Insurance Fairness Bill at www.usa.gov/state-consumer.

Advocate for change!

Visit www.amplifyyourself.org and tell your story of your insurance denial. Here you can share your story, get involved with Amputee Coalition’s advocacy, and send your story to the CEO of your insurance company, as well as your state and federal legislators. With many stories, like yours, our leaders will be able to understand how the denial of appropriate assistive devices is a universal problem across the country, keeping individuals from living their lives to their fullest potential. This tool has not only been helpful in changing insurance policy and coverage of assistive devices, but it has also been helpful in overturning individual appeals.

Related Resources

Amputee Coalition
amputee-coalition.org
Insurance commissioner
naic.org/state_web_map.htm
Contact your state legislators
usa.gov/state-consumer
Contact your federal legislators
senate.gov/senators/senators-contact.htm
house.gov/representatives
State assistance programs
usa.gov/state-health
Centers for Independent Living
ilru.org/projects/cil-net/cil-center-and-association-directory