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Appealing an insurer’s decision can be overwhelming and confusing. Below we’ve provided helpful advice and examples of appeal letters to use when you ask your insurance company to reconsider their denial of coverage.
Not medically necessary
You must prove the medical provider thinks the recommended treatment is medically necessary. Ask your doctor - and perhaps other medical experts - to provide written documentation explaining why.
Experimental
Experimental treatment may be covered if you or your medical provider can prove it meets one or more of the following conditions:
- Medically necessary and considered standard treatment by the medical community.
- The only treatment that will work (show what you've already tried).
- Less expensive than standard treatment.
- A procedure that's been covered by your plan in the past for patients with the same medical condition - this is something your provider might know.
Mental health and substance abuse
Your health insurer must provide you with the same level of benefits for mental health and substance abuse disorders, such as office visits, as they do for medical and surgical services. Ask your doctor to provide written documentation explaining why it should be covered.
Gender-affirming care
Generally, your health insurer cannot exclude, deny or limit medically necessary gender-affirming treatment. Ask your doctor to provide documentation to show medical neccessity of the denied treatment or service.
Out of network
Try to show your plan didn’t have access to a provider with the needed specialty in-network, or there was an unreasonably long wait time for an in-network provider.
Health care setting (e.g. in-home care vs. hospitalization)
In-home care instead of hospitalization may be covered if you show that in-home care would be less expensive and will meet the medical needs of the patient. Show that your provider recommends the best care is in-home care instead of hospitalization. Provide an in-home care treatment plan approved from your provider.
Depending on the type of plan, it may help to cite state rules (leg.wa.gov).
Policy cancelled for lack of payment
Explain why the payment wasn’t made, such as a payroll error, or a new bank account was established and you forgot to notify the insurer of the account change. Explain that you have been a customer for a long time and have always made your payments on time. Ask your insurer to make a one-time exception and reinstate your coverage.
External review by an independent review organization (IRO)
The external review is one of several steps in the appeal process when an independent third-party reviews your appeal to determine whether the insurer should cover your claim or not. It's requested after you've exhausted your insurance company’s internal review process without success. To check out other IRO decisions for health insurance appeals, use our searchable database (fortress.wa.gov).