Starting the Appeal Process

It can be hard to know how to organize yourself as you move into the appeals process. You as a plan member have the right to the full length version of the plan’s medical policy or a copy of the information used to make their denial decision. You should request this documentation for your records.

Your best documentation and evidential support for your appeal will come from your plan language. Most likely this info will be within the plan definitions for Covered Benefits, Non-Covered Benefits and Exclusions.

When preparing for your appeal, seek additional support from your medical provider including a statement of medical necessity, and documentation of prior treatments and the reason the treatment or service in question was being ordered.

You may be able to successfully appeal if you and your provider can show that the treatment you require is currently considered to be the standard care by medical providers. Standard of care is a formal diagnostic and treatment process a doctor follows for a patient with a specific illness or set of symptoms. Also known as ‘best practice’, the standard follows guidelines and protocols that are agreed upon by experts in the field.

Some things to look at include:

    • Are there clinical studies or peer reviewed journal articles that support the treatment?


    • Did your doctor participate in a peer-to-peer review with the medical director of the insurance company?


  • Does Medicare or any other insurance company already cover this treatment?

If you have been unable to receive the care because your insurance has denied it as outside of standard of care, ask your medical provider if the treatment is available through a clinical trial instead that will not further delay your access.

More Expert Articles From PAF