How to get in-network coverage for out-of-network medical treatment

Check out our services available to help you navigate health insurance coverage for expensive treatments. These includes choosing an insurance company, writing appeals, and creating a plan for insurance coverage.

‍

This appeal-writing guide (and our service of writing appeals) can be used by patients or providers. We can help anyone that’s facing a denial from an insurance company.

‍

Join our online community of patients fighting their insurance companies to cover medical treatments (it’s early stage right now, but it will grow quickly as we promote it through other subreddits): https://www.reddit.com/r/FightInsuranceDenials/.

‍

Our guide below was inspired by the following sources:

1. Laurie Todd, the Insurance Warrior. See her books here. (Her book “Approved” is pictured below on the left, alongside a photo of her.)
2. The National Alliance on Mental Illness. See their appeals guide here.
3. Cancer Legal Resource Center. See their guide here.
4. 50+ other experts we’ve consulted with, including lawyers, healthcare providers, insurance company employees, patient advocates, denial management firm representatives, and patients themselves

Insurance company denials can be overturned far more often than you’d think. Treatments, especially expensive surgical procedures and inpatient behavioral health treatment, get denied by insurance companies every day, but they can often be overturned even when the insurer explicitly states that the treatment isn’t covered. In fact, your insurance company has probably paid for your “non-covered” treatment many times before, they just don’t want you to know about it. People always ask if they should appeal their expensive treatment denial, and the answer is yes. There are many reasons insurers deny treatments: unqualified medical reviewers, straight-up mistakes, or rejecting treatments without any human review. Also, even if they clearly state in their documentation that they won’t cover your procedure, you can still potentially win an appeal; just because they claim something doesn’t make it true. For these reasons and more, your odds of overturning a denial are higher than you think.

‍

You must be your own advocate. In cases where the traditional appeal avenue through your physician fails, it’s up to you and you alone to fight your insurance company.

1. Your doctor won’t go beyond the traditional appeals process, and some physicians (and often the best surgeons) don’t deal with insurance at all. They’ll require you to pay up-front and then pursue any reimbursement from your insurance company later. In these cases, the appeals are completely your responsibility.
2. Regulators won’t fight for your specific case. While they can inform you of relevant laws and keep an eye on insurance companies, they won’t advocate for your case directly.
3. Lawyers usually won’t take these cases because there isn’t enough money involved (some lawyers might work with you if the treatment is $200,000+) and they don’t believe the cases can be won often enough (based on our experience, we disagree). Plus, if your case isn’t cut-and-dry such that the insurer should definitely pay for it, then lawyers are even less likely to get involved.
4. AI tools like ChatGPT can’t write your appeal for you. It’s just far too complex and nuanced, not to mention customized to your specific case. (Plus, you don’t want to put your personal medical information into those algorithms.)

The appeal itself should follow a very particular format: cover page, table of contents, summary, each corresponding section, and an appendix. Don’t be intimidated, it’s worth it for your life-changing medical treatment. This guide will teach you everything you need to know, and we also offer one-on-one consultations and holistic appeal-writing services described here.

‍

When writing your appeal, you must picture yourself as a courtroom lawyer proving your case, meticulously compiling and describing all important evidence and addressing objections proactively. You should dismantle their plan documentation (which is never very good to start with) and show in their words why your treatment should be covered. Note that as a “courtroom lawyer,” you need to be unemotional: emotional appeals like “my kids need me not to be sick” and “I deserve to live” don’t work with insurance companies. While you should describe in your appeal the symptoms of your medical disorder and the bad communication you’ve had with the insurance company (see detailed descriptions of both below), you should do so in a matter-of-fact way.

‍

An appeal is a formal request for a review of an insurance company’s decision to deny coverage for a specific medical treatment or procedure. This process allows the insured individual to present additional information or arguments to support the necessity of the treatment in question.

‍

The appeals process is largely the same regardless of your insurance plan. They’re all about proving your case, which is done similarly for any insurance coverage around the world.

‍

Expensive treatments usually require a prior authorization (sometimes called a “precertification”) from your insurance company. This means that your physician (or you) submits your medical information for them to determine whether the treatment is covered before it happens. Surgeons will typically send your insurer a collection of your information and a stock letter that they write for every patient. This letter is usually quite comprehensive, but insurers might not be convinced because physicians tend to use the same letter for all patients. If your treatment is denied, then your physician can go back-and-forth with your insurance company, including a “peer-to-peer” review with a doctor working for the company (but note that these doctors usually aren’t qualified to make decisions about your complex treatment). Usually this works out and you don’t need to get involved, but when physicians exhaust their traditional appeals process, there isn’t much more they can do without you.

‍

You can usually request external review if your insurance company denies coverage (meaning someone outside of your insurance company reviews your case), and if you win this review, the insurance company must pay. But be warned that if you lose, the external review result could be used as precedent of a denial by your insurance company if you want to appeal further. Some consumer advocates point out that they could be biased against the patient because many Independent Review Organizations are selected and reimbursed by health plans. Statistically, external reviews are more successful than internal reviews, with some states like California reporting that 60% of appeals filed by patients are determined in favor of the patient.

If the treatment has already happened and you want to be reimbursed, it is still possible to go through the appeals process but it generally takes much longer and anecdotally has a lower success-rate. When possible, we strongly recommend appealing before the treatment happens; with the strategies in this guide, the appeal can be expedited. If you’re appealing after the treatment has taken place, keep in mind that some insurance companies have a maximum amount of time for which to file an appeal (although you can always try to appeal after that deadline, if necessary).

‍

Decide on your treatment provider first. Insurance claims and appeals are designated for a specific treatment with a specific doctor. In other words, your case is attached to your treatment-provider; approvals for the treatment regardless of doctor aren’t possible.

‍

Most health insurance plans tend to have very similar appeal processes and strategies. This guide should apply in almost all cases regardless of insurance plan; fill out our intake form if you aren’t sure about your situation.

‍

If your insurance plan is self-funded, then any insurance denial can be appealed directly to your employer after you’ve exhausted traditional appeals. “Self-funded” means that your employer is the one to ultimately pay for your treatment and your insurance company just handles administrative matters; this is the opposite of “fully funded” in which your insurance company pays for the treatment. Most people with commercial health insurance are on self-funded plans; they just don’t know it.

‍

‍

Insurance companies typically have a complaint system, but these are generally more relevant for administrative matters rather than denial of medical treatment. Just using their complaints channel won’t get your treatment approved.

‍

Patients can also seek legal counsel or assistance from a patient advocacy organization. Just keep in mind that anecdotally, lawyers often don’t take these cases because there isn’t enough money involved, and traditional patient advocacy organizations typically won’t provide the depth of appeal described in this guide (we offer a service that does, see here).

‍

You can file a complaint with your state’s insurance commissioner (or relevant national body depending on your plan)

‍

For starters, you need all forms of documentation listed below.
‍

‍

Your insurance plan document

This document explains your insurance plan’s entire medical policy to you. This should be 80+ pages (not the short booklet; that’s a different document), and it can be called a variety of names including “medical benefits booklets,” etc.
‍

‍

Plan documents tend to contain the following information

‍This is a typical layout of an insurance plan document:

1. Table of Contents
2. Introduction
3. Definitions
4. Eligibility and Enrollment
5. Effective Date of Coverage
6. Types of Coverage (e.g., individual, family)
7. Premiums and Payments
8. Benefit Summary
9. Covered Services (with many sub-sections)
10. Exclusions and Limitations
11. Coordination of Benefits
12. Preauthorization Requirements
13. Utilization Management
14. Claims Filing and Payment
15. Explanation of Benefits (EOB)
16. Appeals and Grievances
17. Continuation of Coverage (e.g., COBRA)
18. Termination of Coverage
19. Reinstatement
20. Amendments and Endorsements
21. State and Federal Regulations
22. Privacy Practices
23. Fraud, Waste, and Abuse Prevention
24. Miscellaneous Provisions
25. Contact Information
26. Glossary

These sections may vary slightly between different insurance companies and plan documents. Always consult your specific insurance plan document for detailed information about your coverage.

Don’t let your insurance company delay sending this information to you. Insurers will often delay or avoid sending this document, but they’re required by law to provide you with it in a timely manner. We recommend (politely) reminding them of this when you’re on the phone with a representative; it’s fair to ask for those documents within one business day.

‍

You need to know exactly which company is insuring you, which can be found in your plan document. Keep in mind that it might not be obvious; there can be a variety of companies working together on this. Insurance companies can go by different names, or similar-sounding companies can be totally different from one another (this is the case with Blue Shield companies). This becomes important when you find the list of people to send your appeal to.

‍

It’s very important to know whether your plan is fully-funded or self-funded, see explanation in above section. If the plan is self-funded, you should also loop in your employer’s HR department.

‍

Understand whether your insurer claims to require “step therapy” before your treatment-of-choice, meaning cheaper/less-invasive treatment attempts before opting for the major surgery. For example, in cases of obstructive sleep apnea, some insurance plans require the patient to test out CPAP therapy before getting double jaw surgery. If you already did the first-step therapy, document that. If you haven’t done it and/or don’t want to, should provide justification in your appeal about why you aren’t a candidate.

‍

Understand whether their documentation allows for “benefit exceptions”, “treatment not available in the network”, or “unique circumstances.” If they do, you should feature those statements prominently in your appeal letter. If they don’t, no worries.

If your procedure has been denied already, use those denial letters to understand the exact reason they give for denial and who at the company is denying it. If you no longer have those letters, you can ask your insurance company for them; ensure that they send it to you quickly.

‍

These denial letters, which form the basis for your appeal, typically include:

1. The specific treatment codes that were denied (these are CPT codes that form a universal language to describe treatments between physicians and insurance companies). A major procedure typically has multiple treatment codes, and sometimes some will be approved but others aren’t. In this case, you just need to appeal the codes that aren’t approved.
2. The reason(s) for denial. This includes not being medically necessary, being considered experimental/investigational, etc. In your appeal letter, you’ll disprove each reason separately.
3. Specific guidelines and policies they used to deny your appeal. You’ll use these as a baseline, either showing how those policies actually support approval for your treatment or dismantling the guidelines as illegitimate.
4. Specific documentation that they don’t have. Sometimes, your physician doesn’t send everything they need to give an approval, in which case they will deny it. If this is called out directly, make sure to assemble this evidence as part of your appeal.
5. [Sometimes] Scientific literature used to make this determination. If this isn’t cited directly in the appeal, you can find it cited in other documentation. As described later in this guide, you can dismantle these studies compared to other studies or even show how the studies actually support your treatment-of-choice (this happens more often than you’d think).
6. [Sometimes] The medical reviewer who denied the claim. You can use this information as evidence that the reviewer isn’t qualified to review your case (covered more below); they’re usually just general doctors, not experts in your procedure. If there is no reviewer named in the letter, you can still write in your appeal that you have no confidence that the reviewer is qualified to make this determination.
7. How to appeal the decision. This information is also contained in other insurance plan documentation. You’ll want to follow this process, but you should also do even more (such as sending your appeal to specific contacts at the insurance company), described later in this guide

‍

Get around your insurance company’s long review turnaround times by getting, a letter of medical urgency from your doctor. Insurance companies usually give 30-90 days for reviewing your appeal, but you can get around it by having your doctor write a note that it is medically necessary for you to get an urgent review; that often means they’re required by law to make a decision within 72 hours, and anecdotally this seems to increase the odds of approval. “Medical necessity” doesn’t mean you need to be dying; there could be a variety of reasons for medical necessity, and we’ve never heard of a circumstance where insurance companies denied the request for medical urgency. If your treatment doctor won’t write the note, try to get your primary care doctor to write the note

First, understand from your plan document how much it indicates that your procedure should be covered. Procedures fall into two categories:

1. It’s cut-and-dry that your insurance plan should cover your treatment (in other words, they clearly made an error in denying coverage even after your doctor appealed through traditional avenues).  If it’s simple and obvious that it should be covered, you don’t necessarily need to write a 20-page appeal, but you still want to be proactive in writing a short, powerful, evidence-based note that getting it to the correct stakeholders, see advice below. If that fails and you’re 100% convinced that you should be covered, then you can move on to “external review” (see above section) in which someone outside the insurance company looks at it, and if they overturn the denial, the insurance company needs to pay. However, be warned that if the external reviewer upholds the denial, the insurance company can cite that as precedent when you appeal later.
2. It’s not cut-and-dry. This could mean that it’s a grey-area of coverage, or the insurance company specifically states that they deny the treatment (this can still be reversed, by the way). If you’re in that situation, you need to write the entire long appeal to maximize your chances of approval. Follow everything in this guide to maximize your chances. Remember: you can win these.  

You should have a general understanding of what your procedure is, the medical justification, and why it is better than other procedures to treat you. This is achievable as long as you’re internet-literate. Of course, your doctor is the ultimate source of truth, but significant information is available from credible sources on the internet.

‍

Remember: just because they say it’s not medically necessary, doesn’t mean it’s not medically necessary. Don’t be discouraged! There is no government organization that defines what is medically necessary vs. not. Insurers will cite official-sounding organizations like the National Comprehensive Cancer Network, but these are private companies for whom insurance companies are the customer.

‍

You need to do significant research. This distinguishes your appeal from that of other patients. This is a major time investment. This guide contains everything you need to know to tackle this on your own, but our appeal-writing service can handle it all for you

There is no specific rule on how to structure your appeal letter, but we’ve found this format to be the most effective for conveying your point and all of the supporting arguments. It’s a modification of Laurie Todd’s appeal letter structure from her book “Approved.” Overall, this technique will result in your appeal letters being much more comprehensive than other appeals, and that’s a huge advantage.

‍

The difficulty here is organizing the large amount of information into structured form, and you’ll likely need to iterate on it a couple times. We’ve created this structure based on our experience writing many long appeal letters, and we recommend sticking to it in order to be comprehensive and to ensure the most important information is presented in an easy-to-digest format.

‍

There are a few principles you should abide by in writing every aspect (each detailed below) of your appeals:

‍

1. Be long and comprehensive. You need to throw everything at them. They might not read the whole thing, but the length itself speaks volumes. You want to give them no loose ends they can point to as a means of rejection.
2. Boil everything up at the beginning. Your appeal will start with a terse summary (see below), and you should write that summary as if it’s the only part they’ll read (because it might be), and it includes every aspect of your argument. Everything else is supplementary evidence. Specifically, there are three “layers” to the appeal letter: (1) summary, which contains all of your core arguments, (2) specific sections, which go into detail on each argument, and (3) appendices, which cite all of the sources you used in bulk.
3. Don’t use emotional arguments. Statements like “my kids need me to be alive” and “I deserve to live” are not convincing to insurers who view the accurately as a contractual dispute. Using these arguments will hurt your case because it limits your credibility, so you should be factual and to-the-point, like a lawyer in a courtroom.
4. Prove your point with the language they use in their documentation. Frequently quote their document (which, by the way, the reviewer might not have even consulted when they rejected your case) to support your case, in some cases stating how it supports your argument and in other cases refuting their language as non-applicable or nonsensical for your situation.

Start writing somewhat early in the research process, while you’re still gathering information. This way, you’ll get a sense of more research to do, where the gaps in your arguments are, etc. The overall structure appeal letter structure presented in this guide will help

‍

It’s likely that your insurance company has paid for the procedure you are seeking before in cases like yours, but this isn’t public information. You should try to find these cases.

‍

Use online support groups for your diagnosis or your procedure. Ask for anyone who has had this procedure before, and scroll back in time to see any posts or comments. Ensure that you get their permission to use their full name and some high-level medical information in the appeal.

‍

You want to list a large volume of cases of your treatment, but prioritize ones where…

• Your insurance company was the one paying(or Medicare, because everything is based on that)
• Their diagnosis is the same as yours

We have many prior cases available to cite for your appeal letter; fill out our intake form on our homepage to learn more.

This is the meat of your appeal; it will be the longest section. Denial based on medical necessity is rarely given as a sole reason, but it’s usually tacked on to something else. Regardless of the stated reason for denial, you must prove medical necessity in your appeal; otherwise, you risk them turning around and saying it’s also not medically necessary, denying it again.

‍

A. Show why it’s medically necessary by their definition

Look at their definition of medical necessity, and address why your procedure meets those criteria line-by-line. An insurance company’s definition of medical necessity will look something like this (Make sure to use your insurer’s exact definition for your plan, as they do vary to an extent.): “Medical necessity means that the health care services, supplies or medications are required and appropriate for the diagnosis, care or treatment of a covered person’s illness, injury, or condition, in accordance with accepted standards of medical practice, and are not primarily for the convenience of the covered person or provider.”

‍

B. Provide the overall rationale for your procedure

You must explain why this procedure is being done. As an active patient, you should know this anyway. This can be lengthy, but it’s worth it. This sub-section is frequently referenced in the above sub-section.

‍

As part of this, you need to prove that there is no alternative treatment. Cite literature on the efficacy of your preferred treatment over the default. Bonus points if it’s the literature cited in their plan document, as those studies often say the opposite of what the insurer claims.

‍

Whenever you cite something, provide a direct link in the footnote and add the source to the bibliography.

‍

If you stumble upon a point that you’ve already made, just reference that other part of the doc (ideally in a subsection of the overall “medical necessity” section). This should cut down on the amount you need to write.

We can write out the medical necessity for your appeal in a way that has succeeded for patients before (and we incorporate many scientific studies to back it up); fill out our intake form on our homepage.

Health insurers have a specific set of treatments that they’re used to paying for, and they’ll characterize everything else as “experimental” or “investigational.” Don’t let this vocabulary intimidate you; there is no official government designation of what’s experimental and what’s not, rather the insurance companies decide. There are “guidelines companies” that make these determinations, but these companies directly partner with insurance companies who have an obvious incentive not to pay for expensive treatments. Even if they consider your treatment experimental, it’s likely they have paid for it before. You can win these.

‍

Just like with medical necessity, you should find the guidelines for what is experimental in your plan document, then break them down one-by-one. Possible reasons you can cite that it’s not experimental (see their definition of “experimental” for a complete list):

• It’s been done a long time
• It’s not in a trial
• Lots of publications
• Surgeries aren’t regulated by the FDA

There will be overlap with the medical necessity section above, and that’s okay. When that happens, just reference the point you’ve already made in the above section (and if possible, provide a link to it).

‍

If the procedure is explicitly called out as experimental or investigational (or otherwise explicitly excluded by the insurance plan), it becomes harder but not impossible. You take the same approach of going line-by-line to dismantle their definition of experimental.

‍

There is much more nuance with each specific case; feel free to set up a consultation for us to discuss your case

This section combines multiple angles to show how you haven’t been treated fairly by the insurance company. While insurance companies aren’t typically too bothered by their poor treatment of patients, documenting your experiences here might show them that this could be a liability, thus encouraging them to approve your request

These are your listing of everything. The sheer quantity will help show that you’re serious. Don’t expect your recipients to read all (or any) of the content here, but their presence shows the weight of evidence on your side. If they review your case in-depth, they can refer to certain elements as mentioned earlier in the do

‍

A. Medical literature citations

This is just a section to show how comprehensive you’ve been in your research. Most of these sources have been cited and linked separately throughout the rest of the appeal letter document, but this section states them all again. You can also cite extra studies that you didn’t call out directly; just make sure to have seen their abstract before (quantity will show that you’re serious and well-researched).

‍

This should be very easy to create if you use the bibliography software.

‍

B. Precedent: cases where this treatment has been approved before

List out all cases of precedent here, one by one. Include relevant information about diagnosis, specific insurance company, etc.

‍

C. Laws and regulation

List out links to any relevant ones here.

We have all of the sources to use if you work with us to write your appeal letter. fill out our intake form on our homepage for more information.

Send us questions and feedback via email (alex@paxosappeals.com); we’ll update this guide continuously. As mentioned above, we can also help you write your appeals to maximize your chances of success.

‍

We’d like to extend a huge thank you to Laurie Todd, the Insurance Warrior, who has fought insurance denials for many years. Her book “Approved” (pictured below) gives more information on this.

 The information provided on this website is intended for general informational purposes only and does not constitute medical or legal advice. We are not medical professionals, nor are we attorneys. While we strive to provide accurate and up-to-date information, it is crucial to understand that each case is unique and may require specialized expertise. Do not rely solely on the content found here for making decisions regarding your health or legal matters. Always seek the advice of licensed professionals when dealing with such matters