Appeal! About half of appeals are approved

In this section, we cover:

• Appeal Tips
• External Review
• Expedited Appeals

There are many screening and preventive services recommended for individuals with a genetic predisposition to cancer that go beyond routine care for the general population. See the Risk Management Guidelines for more information. In addition, people with hereditary cancers may require different interventions or therapies than the standard of care for those with nonhereditary cancers. Health insurance coverage and out-of-pocket costs for these services and treatments can vary greatly based on your health plan.

Health insurers may deny coverage for certain screenings or treatments if they are considered not medically necessary, experimental or “off label.” If your insurer denies coverage of a particular treatment or service, you have the right to appeal the decision. It is important to note that applying the costs of a preventive or medical service to your deductible, or applying coinsurance and copays, is not the same as an insurance denial but appeal is still an option.

You have the right to appeal if your health plan:

• Denies coverage of a health care service, supply, item or prescription that you think you should be able to get
• Denies payment of a health care service, supply, item or a prescription drug you already received
• Doesn’t reimburse a health care service, supply, item or prescription drug at the appropriate amount; you can request to change the amount you must pay out-of-pocket

Before filing an appeal, it is important to understand your health plan benefits and exclusions, and the laws governing health care in the U.S. Visit our webpages on the Patient Protection and Affordable Care Act (ACA) and Insurance & Paying for Care for more information.

Tips on filing a health insurance appeal

To begin a standard appeal, you should follow your health insurer’s internal appeals process. Information about the internal appeals process is typically found on any claim form, benefits statement or in the insurance policy paperwork. An appeal usually involves writing a letter to your insurer asking them to reconsider the denial or reimbursement for a specific medical service or treatment. It helps to provide evidence of medical necessity. To assist our community with insurance appeals, FORCE has created sample insurance appeal letters.

Sometimes insurers have two levels of internal appeals. If your claim has been denied at all levels of your insurance company's appeal process, appealing through your state’s external medical review program may be an option.

External Review

All states are required to participate in an external review process that meets the consumer protection standards of the Affordable care Act (ACA). In these programs, an independent group of physicians and professionals reviews your claim and decides whether your insurer must cover the service or treatment. The rules for external medical review vary by state. Most states allow external review in instances when a claim is denied because it was found to be (1) not medically necessary or (2) experimental or investigational. 

In this process, an Independent Review Organization with qualified experts will consider your appeal. You need to show that the screening or treatment is medically necessary in order to win the appeal. Your health care providers can be helpful in presenting evidence and supporting your case. If an external review finds in your favor, the health insurer typically must follow the determination, although specific rules vary by state.

Contact your health plan administrator or state insurance commissioner for questions about insurance appeals and whether an external review is an option for you.

Expedited Appeals

In some cases, an expedited appeal is needed. This may be the case if you have been diagnosed with cancer, for instance, and have not received any treatment yet—or if you are in the middle of treatment and you or your health care provider believes that your condition poses a serious threat to your health. Most health plans offer an expedited process where they respond to you within 72 hours of getting a qualifying appeal.