Understanding Coverage Determination / Appeal Options / Common Reasons for a Denial

Patient Education

Prior Authorization:  A decision by your health insurer that a health care service, treatment or procedure is medically necessary (also referred to as a prior approval or pre-certification).

Peer-to-Peer Review: Typically one individual (a peer) discussing / reviewing the case (usually for insurance approval reasons) with the physician who requested the service.

Appeals:  There are multiple appeal levels and they may differ by insurance plan.  Understand your Appeal Rights.

Insurance companies typically have at least a three-level appeals process, but this may vary by plan.  Appeals at the first level are processed by the company’s appeals staff or by the company medical director responsible for the denial.  Second-level appeals are reviewed by a company medical director who was not involved in the original decision. The third level appeal involves an independent, third-party reviewer, along with a doctor of the same specialty as the patient’s treating provider.

Internal Appeals (Level 1 and 2):  when services are denied, you have the right to an internal appeal. You may ask your insurance company to conduct a review of its decision for reconsideration.

External Review – Independent Review Organization (IRO) External Review (Level 3):  an independent third-party reviews your appeal to determine whether the insurer should cover services or not. The insurance company is not involved in the decision-making of the external reviewer.

Please check the details of your insurer’s appeals process by contacting member service or READ the insurance denied procedures instructions. Insurance companies are required to provide all the tools needed to properly make an appeal. Please be aware of any necessary filing deadlines. Note: in most cases, you must exhaust your insurance company’s internal review process prior to requesting an External Review.

It’s unsettling to receive correspondence from your insurance company advising that your request for medical care/treatment has been denied. Be aware of some steps you can take to help boost the odds of filing a successful appeal or grievance.

Member Complaint/Grievance:  A written or verbal expression of dispute or dissatisfaction with the decision or outcome in which you are asking for reconsideration.

Helpful tips when filing a grievance:

  • Confirm denial reason: Not medically necessary, Excluded, Experimental and Investigational, Unproven etc. You must prove the medical provider considers the recommended treatment to be medically necessary.
  • Stay organized and keep records of everything including your relevant medical records, List of Medical Treatments, Labs, Medication List (tried and Failed) letters from your provider(s) of care, copies of denial letters, etc.
  • Contact your Benefits Administrator (if your insurance coverage is through your employer) and advise them of the situation. Do they allow Benefit Exceptions?  They may be able to provide direction and advocate on your behalf.
  • Enlist the help of your health care provider(s) (Physical Therapist, Chiropractor, Pain Management, Surgeon) and ask that they prepare a Letter of Medical Necessity to support your case.
  • Prepare a Quality of Life Letter. Tell your story. Make notes of exactly what happened, or what’s not happening and the impact of your condition on your daily activities.  Be sure to include details about your treatment and your path forward.  Find additional information in our Patient Insurance Authorization Workbook at  https://si-bone.com/uploads/documents/SI-BONE_Patient_Insurance_Authorization_Workbook__9359-060717.pdf.
  • Follow-up with your insurance company, as Appeals and Grievances can take weeks, even months to be reviewed.

Appealing an insurer’s decision can be overwhelming, exhausting and confusing. The SI-BONE in-house reimbursement program (Patient Insurance Coverage Support or PICS) offers provider and patient education on appeal support, current trends, and best practices to support access to coverage. 
Find additional information at https://si-bone.com/patients/insurance-support/

Important links for patients seeking insurance support:


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