Anyone appeal an ins decision?

My freaking insurance company sent me a letter last week saying they have deemed IUIs "NOT MEDICALLY NECESSARY" and they will not cover any more. I have a funny suspicion this has something to do with my RE accidentally billing my last IUI as an IVF and my ins does not cover IVF at all. They said that I can appeal the decision, but I have no idea how to go about it or what to write in the appeal letter.

TIA

Anyone appeal an ins decision?

Wow thats rough. What does your insurance plan say? Is there a certain amout of IUI or $$ amount? If no, then should still cover you

Re: Anyone appeal an ins decision?

I had unlimited IUIs. The letter said...

"Our Medical director has determined that the request is: Denied - Not Medically Necessary.

After consideration of all available information, our medical director has determined that the requested procedure will not be covered for the following reason(s): Based on health plan criteria for infertility treatment, coverage fot the 8th treatment is denied. The information shows you have problems conceiving after multiple failed treatment attempts. There is not good proof that continued attempts with this process will help you conceive. You do not meet the criteria and the 8th treatment is not covered by your health plan. Please discuss other options to help you conceive with your provider."

NOT MEDICALLY NECESSARY?!?!?!? Besides the low amh, I have pos antisperm antibodies. IUI would be the ONLY way to get pregnant..besides IVF which they do not cover at all. Your medical director is CLEARLY an a-hole.

Re: Anyone appeal an ins decision?

Re: Anyone appeal an ins decision?

Have you spoken to your RE? After reading the insurance company's denial, it seems as though you'd need the RE to assist in the appeal.

I'm sorry you're going through this. IF is difficult enough without having to navigate through all of the insurance nonsense.

Re: Anyone appeal an ins decision?

Posted by GoodThoughts

Have you spoken to your RE? After reading the insurance company's denial, it seems as though you'd need the RE to assist in the appeal.

I'm sorry you're going through this. IF is difficult enough without having to navigate through all of the insurance nonsense.

Anyone appeal an ins decision?

Fight the man, R. Fight fight fight.

Re: Anyone appeal an ins decision?

call the RE's office and ask them what they do in these situations. Do they have a go by? Anything that can help you at this point.

BTW I cannot stand these A-hole insurance companies.

Re: Anyone appeal an ins decision?

Definitely appeal. You may want to look into getting an obudsman who can help get this figured out for you.

Here's one

Re: Anyone appeal an ins decision?

Always if it is something you need. Usually on the back of the denial letter are the steps you need to take in order to appeal. ALWAYS appeal, if you go past the deadline they will say "you didn't appeal on time" so dont wait. It's annoying and a pain in the a## but do it. I was sent the same letter a few weeks ago. Call the RE's office to see what happened and how it was coded or call the insurance company and see how it was coded..Good luck

Re: Anyone appeal an ins decision?

your RE's office needs to put the pressure on, especially since they messed up the billing in the first place.

Re: Anyone appeal an ins decision?

Appeal and have the insurance annoy their ass! That letter was so mean!

Anyone appeal an ins decision?

Omg! R! That's Ridic!!!!!!! Was it your first iui since Ivf?! Curious if they are denying it bc it's your first back. Not that that is Any type of logical sense.

Fight fight fight !!!!!!

Re: Anyone appeal an ins decision?

Definitely as them at RS if there is anything they can do in their end

Unfortunately, the last I spoke to my case nurse at oxford, she said the little IF coverage we do have will be less in 2014. That they are finding reasons to deny a lot of IUI claims if there was no pregnancy after a certain amount. For me, I got pregnant in IUI #3 and went through 3 more. I called to check on their policy being that I did get pg once with IUI, she said I had 1 more IUI and even though they say it's on a case by case basis, they most likely won't give me more then the 1 I had left. Needless to say I was beyond upset.

Oxford, at 1300 a month, is able to dictate how many times I get a fair chance at pregnancy.

They suck.

Re: Anyone appeal an ins decision?

Are you fking kidding me? Like you really need this?? Ugh I would fight it and def get RE involved.

Anyone appeal an ins decision?

I know!!!!! So redamdiculous!!!!! That letter, the way it was worded, was like a kick in the stomach! I mean I wasn't expecting a sympathy card or anything, but come on! I called the insurance company and after being transferred several times to the wrong department, and being disconnected twice, I finally got a very nice man on the phone. He said I could appeal, but he suggested I call the RE first and ask them to do a peer to peer where my dr speaks to the medical director and they review the case together. I'm going to drive to my RE after work and see if I could speak to someone.

I do understand there has to come a time when enough is enough, but that is up to my dr to decide. It is up to the dr to say "I'm sorry, we've tried everything. There is nothing else we can do." But we are still trying different protocols to find the best one.

Thankfully I am lucky that we still have my husbands ins as a secondary, but that has very limited coverage.

To be continued...

Re: Anyone appeal an ins decision?

Good luck. The billing person at your RE's office should be able to help.

When I had my second surgery for my endo, it was out of network. The insurance company tried to deny a lot of the charges as not medically necessary. The doctor's office wound up fighting with the insurance to get it resolved.

I know to the insurance company, it's just about the bottom line, but it's really shameful the way they make people go through hoops to get the coverage they are entitled to.

Anyone appeal an ins decision?

Uhh so sorry. I hope your REs office can take care of it.

Anyone appeal an ins decision?

Make Dr Lydic write an appeal. Get all your med records and send them.

Re: Anyone appeal an ins decision?

So sorry Goldie, these companies realllllyyy suckkkkkkk

Re: Anyone appeal an ins decision?

I am so sorry that you have to deal with this! Health insurance companies can be so incredibly cruel and heartless. Sending you

Re: Anyone appeal an ins decision?

I just got the same letter! Same exact wording. We must have the same insurance company. They denied coverage for blood tests my RE ordered to investigate my repeat miscarriages. Almost $2000. If anyone at any time had told me that the blood tests were "experimental" and might be denied by my insurance company, I would have thought twice about the testing. No one did. My doctor said, "You have a medical problem and we're sending you for blood tests," and I went for the tests. She's my doctor; of course I go by her medical advice. What else was I supposed to do? This is crazy.

Re: Anyone appeal an ins decision?

My original insurance rejected my first IVF cycle but Dr.B fought for me!

Anyone appeal an ins decision?

I was denied for ivf at first. I called GHI and really complained and Dr. B also called for me! Have your dr fight for you!

Re: Anyone appeal an ins decision?

I had to appeal my first IUI insurance decision because they were saying that I didn't have coverage for it when I indeed did!! Long story short, there was a problem with the coding that was used and my RE's office handled it themselves.