HomeHealth InsuranceHow to File an Appeal When Your Insurance Company Refuses to Pay


How to File an Appeal When Your Insurance Company Refuses to Pay — 13 Comments

  1. I have been having serious pain in right side under rib for over 2 years. My primary care has done every they could to get Prestige Health to ok my CT Scan (as I’ve had 2 ultrasounds and many blood test, stool test & more and nothing can be found. The pain comes and goes and when it comes it’s so bad my stomach swells and I get sick to my stomach. I called Prestige Health myself and wanted to know why they would deny my CT Scan…I had one person quietly tell me to go to the ER. I never know from one day to the next what is going on with me..I’m 64 on disability and my life has been ruined over this!!! When the pain comes it’s so bad I can’t walk!! I live in Florida!

    • Wow, Nancy. I’m very sorry to hear this. I encourage you to continue working with your doctor to get to the bottom of your pain. Your doctor is often your best advocate in these situations. I wish you the best of luck.

  2. I have lived with back pain for years.! I have gone thru all the pt and pain clinic and nerve tests before and ultimately had to quit working full time Over the past 3 yrs I’ve gotten worse and can’t even be on my feet for more than an hr and my legs go numb and I get shooting pain they my groin! I had X-rays and act and my primary , Er doc, and my neuro surgeon all tried to get an MRI but my insurance wouldn’t approve it! The first letter we got listed 6 points why and what they wanted me to do before they would
    approve it. So I had to jump thru all the hoops agaiin plus here’s
    the kicker they wouldn’t approve unless I quit smoking and would have to prove it??? My DRS OFFICE WAS BAFFLED? Also question my CT scan and wanted clarification. Basically
    questioning medical professionals?? We did end up doing what was asked and resubmitted again only to get another letter stating they didn’t have proof there was a need for one? Even after CT showed that I had spondylthesis among several other things and that my discs have fragmented and piercing my nerves and / or spinal cord! The second letter basically said thru the pre treatment notification process it appears this procedure would not be an epigram expense under my plan? Per the medical directors review of all documents there is no indication I need an MRI?? And it also says with the absence of severe progressive neurological deficits and mri or any advanced imaging will not receive pre treatment notification?? What does that mean? I talked to my drs office and asked her if she appealed or what the process was and she said she did and told me it was out of their hands and to talk to my company’s hr people? I asked her to
    Send me all of the documentation she sent to insurance and she told me she didn’t have it anymore??? I am so confused and frustrated! I guess I just don’t understand how all that works but if 3 drs said I needed one how can they deny it? I would like anyone’s input on this I don’t know what I should do next!

  3. I think this article is about the symptom of a bigger problem.

    If you take your car to the mechanic (in most states) they can’t start work without giving you an estimate of the repair. You make your choice with informed consent.

    When you went for your lab test. There was no informed consent. There was only your expectation that a professional doctor had determined that these test were medically necessary and your insurance company disagreed and sent you the bill.

    If you were a car, this would not be legal.

  4. There is a new trend it appears for lab work for blood to have an out of network Dr look at the results. This adds an amount they determine indiscriminately. It is sent to an out of network doctor so it is not cover. I had to contact the insurance company multiple times on this occasion. My next battle is trying to have insurance pay for blood work not coded wellness. If the blood work is coded wellness I wouldn’t have to pay $300. This is my next battle and I hope I win. It should not matter if the blood work is deemed wellness or diagnoses it’s the same blood work. It’s a game and I hope to win. If you have to have blood work done make sure doctor notes it as wellness not diagnostic.

  5. Issues when an in-network lab is used but the claim is denied as experimental by the insurance. A full price charge of 10x of the In-network price is used and billed to the patient ($500 v $50). It seems unfair that an in-network can change an in-network patient out of network pricing. Appeals were denied.

    • I’m so sorry this happened, Dave. Something similar happened to me several years ago. Of course, there was no way for you to know that your doctor ordered tests that are considered experimental. Ironically, your doctor likely didn’t know either. Each insurance plan has its own rules and it is impossible to keep up. One of the MANY flaws of our healthcare system.

      • There should be a way to have the provider change only what is agreed upon if covered. If not it’s undue enrichment by the lab provider..

  6. I have been going to the doctor .with back pain that is going down my
    leg and hip.my doctor had SENTrequest.TO my insurance company for a MRi.two time in month.they have denied. I am going to therapy 3 days a week. It not helpings, what do I do.help .please, p.s. I have been in pain for over years.

  7. I hate to say it, but I’ve resorted to looking for “coverage bulletins” issued by my insurance company (Cigna). Aetna, UnitedHealthcare and others also have these. These list what procedures and tests will be covered and under what circumstances. If I’m going to have cardiovascular lab work done, for example, I try to find out if there are coverage limitations with certain cardiovascular blood tests. Cigna’s coverage bulletin on the subject indeed lists several tests and their coverage policy(ies) for each. Usually, these fall into one of three categories: (1) Cigna will generally cover the test (no specific limitation, although the test still must be medically necessary); (2) Cigna will cover the test only if certain diagnostic criteria are met (e.g., you must have three risk factors for heart disease); and (3) Cigna will not cover the test under any circumstances. Often the coverage bulletin will say that a certain listed test is deemed experimental or investigational, and thus not medically necessary, and Cigna will not cover it.

    This has saved me some angst, but you can’t always check in advance. So this wouldn’t be practical in an urgent or emergency care situation.

    It’s ridiculous the lengths to which patients (and doctors) must go to try to limit exposure to large medical bills. But knowledge is power, and at least given the system we have, I strongly recommend reviewing these policy/coverage bulletins if possible. They are (by law, I think) on insurer’s websites and relatively easy to find.

    Take care.

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