Insurance Review Boards?

I have done this three times, once by phone to appeal refusal of my chemo wig and twice in person, for MRI denial in 2013 and genetic testing coverage earlier this year. I won in all cases although I required the help of my state insurance commissioner's department to obtain reimbursement for the imaging service. Fines in the form of interest payments were imposed due to the long delay in claim processing (also for pre-authorized durable medical equipment on which they initially only paid half the bill)

It may seem intimidating to sit in front of a company lawyer & doctor at a big imposing conference table after signing into security and being given a badge to wearbut I found it most annoying to have someone calling in from a remote location who I could not see! It might be good to bring someone else along to take notes so you can concentrate on the discussion and maintain eye contact. When the MD in the room started nodding in agreement as I presented my case, I figured they would decide in my favor...

If you think the treatment does not fall under the company definition of experimental, you may be able to show how it is actually on the verge of becoming an accepted standard by citing recent studies. I always brought copies of the pertinent policy guidelines found on the Internet as well as references from well recognized authorities regarding the current status of the issues in question. Perhaps they are just behind on updating their parameters.

All that being said, why aren't the costs of the clinical trial being taken care of by the investigator? I will look for my older posts on these topics and bump them for you. Stay calm and let us know how it turns out.

does anyone have a suggestion on fighting my insurance that will not cover my 6 month follow ups on the breast I had DCIS in ? I wrote an appeal they denied . it will cost me 500 dollars every 6 months

I wonder what kind of follow-up has been suggested. Clinical breast exams and annual mammogram are probably standard and not terribly expensive. Screening should be free under the Affordable Care Act in the USA.

Perhaps you have other factors which place you in a higher risk group such as family history of multiple cancers in close relatives, etc. MRI is often used for those with genetic mutations such as BRCA but that scan costs a lot. Ultrasound is a cheaper alternative however not as sensitive. Maybe your plan has a high deductible.

You need to know what the policy says and why you were denied, especially after appeal. The insurance commissioner's office in your state might be able to help when covered benefits are being withheld. Sometimes you can register a complaint with them on line. Don't give up if you feel it is important to your future health!