Lawyer(?) Options for Medical Insurance Procedure Denial

[Dbeasy 15599]

I had a very expense test denied by the insurance company as not being medically necessary. It was an important test recommended by my doctor that was used to make an important treatment decision. Is there anyone (lawyer, etc) that I can utilize to help fight the insurance company? I'm worred that in an appeals process they will just deny it again if I do it by myself. Really appreciate any help or thoughts.

[Bevo 13900]

2 hours ago, Dbeasy said:

I had a very expense test denied by the insurance company as not being medically necessary. It was an important test recommended by my doctor that was used to make an important treatment decision. Is there anyone (lawyer, etc) that I can utilize to help fight the insurance company? I'm worred that in an appeals process they will just deny it again if I do it by myself. Really appreciate any help or thoughts.

Is this the type of test that shows that a penile implant is necessary? Because, I don't think you can get insurance to pay your strip club bill.

Either way, review the determination letter, request the necessary documentation, call the health care provider's office and then submit your appeal.  If this fails, you can then request an external review from an independent third party. If that rejection is upheld another time, you can contact the Texas state insurance department and request help. The state may review your appeal and work with the insurance company to resolve the issue.

BTW, I am not an expert in this so listen to others as well.

Edited November 6, 2022 by Bevo

[Sawbonz 28229]

Did your ordering physician not appeal it? Usually if the ordering physician speaks with a same specialty peer it will get approved unless the plan explicitly excludes the procedure from coverage. If they did a peer to peer and it still was denied ask them to appeal to the medical director of the plan

 

If the policy specifically excludes the procedure as never medically necessary, experimental, etc you are probably not going to be able to get them to pay for it in which case shop around for the lowest cash price. If the results show something that definitively changes the treatment plan you might be able to get reimbursed on the back end

 

if it's a radiology test try these guys

https://radiologyassist.com/

 

they shop around and get shockingly good deals for cash pay esp if you don’t mind driving a bit. One of my patients told me about them 

[Dbeasy 15599]

Appreciate the input. I’m going to try both suggestions.