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Health Insurance Claim Denial Reasons

Insurers may deny a surgical procedure or medical treatment for several reasons.

Not Medically Necessary

A common denial occurs when your insurance company says your surgery or procedure is not medically necessary.

According to the AMA, medically necessary procedures are:

“health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is:

  1. in accordance with generally accepted standards of medical practice;
  2. clinically appropriate in terms of type, frequency, extent, site, and duration; and
  3. not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.”

Despite this accepted definition, and even if your own doctor may have told you the procedure is medically necessary, an insurance company may still claim you don’t really “need” the procedure, and therefore they will not cover it. Every insurance company has its own definition of what “medically necessary” means, and it can be difficult to understand how to go about overturning that designation on your own.

PRIA Appeals has a team of experts that can challenge a “not medically necessary” insurance denial on your behalf and get you the care you need.

Experimental / Investigational

In some cases, your doctor may tell you that you need a certain procedure or surgery, but you receive an insurance denial because the insurance company claims the procedure is not a mainstream medical treatment.

The language of the insurance denial may claim:

  • The procedure is not approved by the FDA to be lawfully marketed for the proposed use
  • There is insufficient data to show the therapy is superior to established alternatives

In many cases, the procedure or treatment you need may be “new,” and insurance companies often reject claims that involve new procedures or devices because they are more concerned with cutting costs than supporting innovation.

PRIA Appeals has many years of experience supporting innovative medical treatments and preventing insurance companies from using experimental/investigational denials to prevent patients from gaining access to the care they need.

Contract Exclusions

Sometimes, an insurer will deny a claim based on the procedure being excluded in the language of the policy, even if it has been deemed medically necessary. Faced with this type of insurance denial, many people simply give up, assuming that if a procedure is explicitly excluded in the insurance contract, there is nothing they can do. This is not always the case!

While PRIA Appeals will not take on every contract exclusion denial, in many cases it is worth challenging the contract exclusion. It is possible to successfully appeal an insurance denial based on contract exclusion if the contract has been poorly worded, does not follow regulations, or several other conditions.

Revisions or Conversions

A revision or conversion procedure is a surgery or other medical treatment that is performed to address or correct complications related to a previous surgery or procedure. A second procedure may be needed to fix a problem with the first procedure (revision), or replace or redo the first procedure (conversion).

Insurers frequently deny coverage for revisions or conversions even if those complications are serious or potentially life-threatening.

In denying coverage for a revision or conversion, insurers may claim that:

  • The patient was not in compliance with a follow-up program.
  • Only one surgery per lifetime is covered
  • There is no technical proof that the first procedure needs to be corrected or replaced
  • The patient no longer meets the requirement for the surgery

PRIA Appeals has experience fighting and overcoming insurance denials based on revisions or conversions. We can help get you the second chance you deserve!