Over the past few years, I’ve received a few denials of coverage from health insurance companies, and each time I’ve appealed the decision. Doing so doesn’t take much effort, and the payoff can be substantial. In one case, I had just started a new job and didn’t yet have an insurance card despite the fact that my coverage was already in place. Thus, we had to pay out-of-pocket for an appointment at my son’s pediatrician, and then submit the claim ourselves. Despite the fact that this provider was clearly a member of their network, they denied it as being out-of-network — sleazy insurance bastards! Sometimes I get the feeling that their default response it to reject any claim that isn’t submitted directly by the provider (and maybe some of those that are). Anyway, I digress…
I appealed the denial of this claim and, not surprisingly, I won.
In a more recent case, I had my wisdom teeth out. Since the teeth had already erupted, my regular health insurance wouldn’t cover it — rather, I had to rely on my dental insurance. As it turns out, Cigna (my dental insurer) requires a ‘pre-determination’ for oral surgery claims, and sure enough they denied it. Their reasoning was that the teeth were perfectly healthy, and that the extractions were for solely for orthodontic purposes (they explicitly state in their policy that such procedures are not covered).
While I had been referred to the oral surgeon by my orthodontist, he had made the recommendation in the interest of what he termed ‘general dental health’ — i.e., he didn’t necessarily require the space that would be created for his orthodontic manipulations, but felt that leaving my wisdom teeth in place presented a risk for future dental problems. Anyway, I went ahead and appealed Cigna’s decision on the grounds that I might eventually need orthognathic surgery (the oral surgeon came up with this idea and wrote a supporting letter), and that the extraction of my wisdom teeth would pave the way for this sort of procedure.
While the foregoing is technically true in that I might eventually be a candidate for such surgery, there’s not a chance in hell that I’d willingly have my jaw broken just to improve my bite. Anyway, I went ahead and had the extractions done and ended up incurring ca. $1, 300 in out-of-pocket expenses (note that I paid with a Citi card to get the 5% cash back).
Thankfully, I received a letter from Cigna the other day stating that they will cover the extractions and anesthesia. While my dental coverage isn’t nearly as good as my regular health insurance, this decision reduced my bill to $660. Now I just need to wait for Cigna to pay the oral surgeon such that I can get my $600 refund.
The bottom line here is that, if you think that there’s any chance that you have a legitimate claim (and maybe even if you don’t), you should file an appeal. It takes very little effort to do so, and it seems that denials are often overturned.
3 Responses to “Appeal Your Health Insurance Denials”
I badly need orthognathic surgery(which is a procedure generally covered by medical, not dental insurance) due to my nearly 3/4″ underbite, but both the claim I filed 3 years ago and the one I filed recently were denied. I am 19 and still under my Mom’s coverage, which she gets from her company. The insurance is Aenta, but it’s her employer, L3 communications, that specifically excludes orthognathic surgery from the company plan. Can the appeals process described above apply the same for my Mom’s employer, or is it strictly an insurance issue? If anyone has any insight it would be greatly appreciated.
I agree with you on this. I have Cigna as my primary insurance provider. My wife has been seeing a doctor (MD) that is out of network and is also on occasions using some so called Cigna branded experimental treatments (at least in this country-most of the treatments are standard in Europe). The doctor is one of the only ones (out of about 6 we have seen) in the city we live that is effectively treating her. We have had to appeal Cigna’s denials for several claims. It seems that when a claim is sent in they manually key it in and then the computer goes to work and performs an automated claim scan for anything that is “non-standard”. If it finds anything it generates a denial. It then takes an appeal to get a human to review the same computer claim info and make another decision on it. It definitely pays to pursue it and be terse in your appeal letters and tell them what you want and why you should have it. They have actually covered experimental treatments as a result of an appeal we filed that they have written coverage positions on (like their 14 page salivary hormone testing paper). Don’t let that stop you because if you can show them why in the patient’s individual case it is needed they will cover it. Cigna “brands” a doctor/provider as experimental if any claim comes through with an experimental procedure on it. The doctor is then “red flagged” (as they call it) and all future claims for the doctor/provider will be denied even if you are only submitting an office visit. It takes an appeal to “reset” the “red flag” to “green”. But if you send another batch of claims through that have an experimental procedure on it will then “red flag” them again and thus another appeal, etc. to clear it. This has been happening to us and thus we are now getting a family attorney involved to try to keep the “red flag” a permanent “green”. A little extreme since attorneys are expensive and definitely not a “fivecentnickel” move but if you have one in the family see if they can help out. So anyway, this is specific to Cigna I guess but it is FYI info to go along with your denial/appeal info.