Factors to Consider While Reviewing a Denial
Medical Necessity
It is very important to realize that just because the insurer doesn’t think the clinical record supports the need for something, or that a treatment hasn’t been proven with vast clinical studies, etc, doesn’t mean that they’re right. Sometimes, they are. Sometimes, a treatment is just too new for a certain condition, and the benefit to be gained has not been well established. In these cases, especially when there’s not much in the clinical literature about the treatment, it can be difficult to overcome a denial. What you need to be able to do is to provide a clear and concise narrative about the relevant medical history, progression of the condition for which you're seeking treatment, treatments tried – successful and not, and prognosis. Then you need to show what the options for treatment are. It is very helpful to ask your doctor for any peer reviewed articles or other medical literature that supports the use of the treatment you've requested for your condition.
You should always request the clinical policy relevant to the service you've requested from the insurer. This will list what criteria they consider appropriate for the treatment of a condition, what they don’t, and why. These include citations that can be helpful to build a case, as they may be outdated or fail to include important developments. You can see an example of a clinical policy that an insurer may use to evaluate a request for coverage here.
In addition, the person reviewing the request for service must take into account the age, history and prognosis of the member requesting the service. In some cases, what might not typically be considered appropriate for the average person without first trying more conventional treatments, could be the most effective and least risky long-term for you.
For example, in a case where a young person has significant degeneration of the lower back vertebrae, and has failed non-surgical treatments, spinal fusion would be the standard treatment under many of these clinical policies. However, there are alternate options that might be more appropriate, but may be considered experimental. The insurer's argument may be something like this – fusion is the standard, but these are the risks, complications and long term problems (ancillary vertebrae degeneration, etc). In addition, there are the adverse impacts on permanent function – ie. Loss of mobility. One can reasonably argue that the person is young, and that the alternate approach is less impactful, has good clinical outcomes with minimal adverse impact, none of the loss of function, etc associated with fusion, and that given the age, and the prognosis, it is the most clinically appropriate treatment for the condition.