appealing insurance coverage denial

anyone have any experience with this? I am working on my appeal letter..

Re: appealing insurance coverage denial

I've appealed claims before, but I was able to do it over the phone

Re: appealing insurance coverage denial

No experience but if you want to post it we can tell you what we think (or FM)!

Re: appealing insurance coverage denial

What is the appeal for and whos the company and what type of plan do you have? PPO or HMO?

I just stoped working, but I was working at Empire BCBS for yrs...I can help you.

Re: appealing insurance coverage denial

Thank you ladies for offering to look it over..this is what i have so far..the only thing i still have to add is the dollar amount..

Aetna
P.O. Box 14001
Lexington, KY 40512

July 31, 2007

Dear Claims Review Department:
I am writing to appeal Aetna’s decision to deny coverage of Intravenous Immunoglobulins (IVIg) treatment. Aetna has denied coverage for IVIg, stating that the treatment is experimental and has not been shown to be effective.
Having to go through one miscarriage is heartbreaking; experiencing multiple miscarriages is absolutely devastating. Women who have autoimmune issues and elevated levels of natural killer cells resulting in recurrent miscarriages benefit the most from IVIg treatment. You should note that studies have shown a success rate as high as 80% with IVIg treatment.
My physician and I determined that due to autoimmune issues I have, IVIg is medically necessary in order for me to sustain a pregnancy. (See enclosed letter)
My first miscarriage, for which I needed to have a D&C done resulted in bills of $XXXX. (see attached claims). Additionally during the 2006-2007 I have had many other expenses related to my two additional miscarriages such as testing, procedures and treatment.
As a member of Aetna I am requesting that you reconsider your denial for this service as it is a medically necessary procedure for my situation.
If there is any additional information I could provide to you that would expedite this matter, please feel free to contact me. Thank you for your time and assistance in this matter.

Sincerely,


LR


Enclosures:
A copy of a letter from Aetna first approving coverage for IVIG
A copy of a letter from Aetna denying coverage for IVIG
Letter of support from my physician
Research articles supporting the effectiveness of this treatment
Medical Claims

Re: appealing insurance coverage denial

I think it is great--have you gone to the yahoo immunology board? You need a yahoo e-mail but once you join there is a whole file on insurance appeals. I'm not sure I would mention the expense(since that might make them wary) Check out the board before you send it and see if they have any tricks. Great idea to include research. I would also quote research in your letter like according to Jones, Smith IVIG has shown the greatest success in RPL-you know what I mean. Good luck. I've heard that the magic number for approvals is 3 appeals. I also read that if you call and speak to one of their nurses that might help you get approved. GL!

I will be doing this soon as we just did a treatmentr that cost $17,000!!! And the Dr doesn't take insurance. Us recurrent miscarriage people are the red headed stepchildren of IF unfortunately. My husband and I are looking into starting a non profit org with a chat board and other services so this doesn't have to be like an underground railroad(as far as findinjg Dr's, treatments being covered, legalizing LIT, etc.) You know I'll be rooting for you.

Re: appealing insurance coverage denial

I had to appeal my IVF coverage to Aetna. I had my doctor write a letter as well.

Re: appealing insurance coverage denial

Thanks for your input..one of my other friends who works for an insurance company reccomended putting the $ amount of the cost associated with my miscarraiges to show how they could be saving with the treatment etc..we will see..

Melissa - you turned me onto the yahoo baord a while back and i am there every day...an amazing resource for women dealing with RPL and immune issues. I used there insurance letters and had my dr sign it...I have attached it in case anyone can benefit from it. I am defintly including that in my claim as well..

as for red headed step chidlren..absolutely..

i think i really realized that when i was figting to get my insurance to approve the costs of an hsg to see if there were any abnormalities in my uterus. I was told before they would cover i needed to register with the infertility hotline..ok no problem..i call to do that and i am told there that i do not qualify as infertility because and i quote " i am successfully getting pregnant" mind you this was 3 days after my 3rd miscarriage and i just lost it..in between sobs i told this woman that successful pregnancies were when people actually had a baby and that i was not getting off the phone until someone gave me coverage for this test..eventually and 2 people later they did..the other thing that bothers me is the insurance dagnosis..recurrent aborter..i told them they also need to chaage that language or at the very least not use it with clients.

i think the idea of starting a non- for profit is a wonderful idea..much needed

Re: appealing insurance coverage denial

Re: appealing insurance coverage denial

thanks so much...I will make sure to bring that point home..

it is good to know we are not alone and no matter what our paths being able to talk to women who are all in the same boat..fighting to do what we need to do to be parents is the best support ever!