If your health insurance company ever denies payment for treatments, services, or equipment necessary for your multiple sclerosis (MS), you have the right to appeal that decision. This means that you or your health care provider may submit a letter and documentation asking the insurance company to reconsider its decision to deny payment of a claim for services rendered.

Every person with health insurance, whether it’s a public or private insurance plan, maintains the right to appeal insurance decisions. Since insurers are under increased pressure for health care cost containment and many MS treatments and disease-modifying therapies are very expensive, insurers may potentially deny or limit coverage of specific MS medications, treatments, or equipment. If you have MS, it is important to become aware of the process of appealing health plan insurance coverage decisions.

How To Appeal a Health Care Decision

A health insurance company may make the decision not to pay for the treatment you need and will send you a denial letter stating that the services or treatment you are seeking are not covered under the provisions of the insurance plan policy language, and are outside contract obligations. However, if you and your health care provider believe you need the treatment or service that was denied, you can and should appeal it.

MyMSTeam members discuss their experiences submitting appeals for health insurance decisions. “Appeals are always worth a try. I have won the appeals I filed,” one member said.

You may appeal an insurance denial at three different times:

• Pre-service (before you receive the care)
• When you receive a prior authorization denial
• Post-service (after you receive the care)

The health insurance company’s denial letter will contain instructions, timelines, and rules for submitting an appeal.

Steps for Appealing

Appealing an insurance denial may feel complicated. Following the steps below can help you stay organized.

Revisit Your Insurance Plan Manual

When considering sending an appeal, the National Multiple Sclerosis Society recommends first reviewing your insurance plan manual to understand why the insurance company may have denied payment for the service or treatment. If it is unclear whether the treatment is covered, then you may have a higher likelihood of winning the appeal. If the health plan policy notes that the specific treatment is excluded from coverage, then your chances of winning the appeal are lower.

Review the Explanation of Benefits Letter

When your insurance company pays for any service or treatment, you’ll receive an explanation of benefits (EOB) letter that explains which services you received that were subsequently billed to the insurance company for payment. If the insurance company denies payment for any of the services, you’ll get a statement and explanation for the denial of coverage in this letter.

Read and understand the insurance company’s reason for denying payment. There are several reasons why the insurer may deny coverage, and your appeal must directly address the reason that payment was denied.

Write a Letter of Appeal

Next, you will need to write a physical letter of appeal. This letter should be simple and straightforward, and should clearly explain why you believe the claim should be paid by your insurance company. The letter should be short (about one page) and include the following information:

• Insurance ID number
• Claim number (if applicable)
• Name and contact information of the health care provider who provided the service
• Date of service (if applicable)

You may also include findings from research studies in your letter to support your case. For example, if a research study showed that people with MS and other similar characteristics to yours fared better on the specific drug for which your insurance company is denying coverage, consider including that information in your appeal.

Use the appeal instructions in the EOB letter you received for information on where to send the letter and for important deadlines. Your appeal must follow all of the guidelines set forth by the insurance company in order to be considered.

Keep a Record of the Appeal Process

It’s very important that you keep a record of the appeal process to increase your chances of winning the appeal and getting reimbursed for the cost of the service or treatment. The National Multiple Sclerosis Society recommends you keep a detailed record of interactions, like the names and contact information of insurance representatives you speak with and dates of contact. The organization also advises that you keep copies of documentation like claims, medical records, denial letters, appeal letters, attachments, and any other relevant documents.

Follow Up During the Appeal Process

The first appeal you submit will initiate what is called an internal appeal, during which the insurance company will do a full review of its decision to deny payment for your claim or prior authorization.

If your appeal is denied, you may follow up and submit another appeal, which will initiate an external review. An external review involves another review of your claim and appeal by a third party, or a professional who has no connection to your insurance plan. It is important to know that if your first appeal is denied, you must follow up to initiate an external review. This process will not be done automatically.

Involve Your Health Care Provider

Discuss any plans to appeal insurance decisions with your health care provider. They may be able to assist you with the appeal process, or they may prefer to file the appeal for you. If coverage is denied over the necessity or value of a treatment or medication, your physician may be able to offer advice or support in the form of a letter. If your physician prefers to handle the appeals process, the National Multiple Sclerosis Society offers appeal letter templates for health care providers.

If you decide to file the appeal on your own, still make your physician aware of your plans. Ask your doctor to provide a letter of medical necessity, which would describe your medical history and situation and provide an explanation for ordering the denied treatment. A physician’s letter could provide invaluable support to your claim appeal process.

Finally, it is important that you do not duplicate efforts. The appeal should only be filed once — by you or your provider. Confirm with your provider who is filing the appeal, as double-filing may cause delays in the appeal process.

Types of Health Care Decisions You Can Appeal

When making an appeal, you must respond to the insurance company’s reason for denial of coverage. There are several reasons for denial that you may appeal, including the following:

• Care is not medically necessary or appropriate.
• Service is not a covered benefit under your insurance plan language.
• Care is experimental or investigational.
• You have a preexisting condition.
• Care is from out-of-network providers or facilities.
• Your plan canceled your coverage retroactively.

Below are some examples of cases in which you can make an appeal:

• Your health insurance plan will not cover a prescription drug that your doctor prescribed for your MS (e.g., the drug is not on their formulary, or list of covered drugs).
• The amount of reimbursement for a prescribed service, item, or piece of equipment you need for your MS is much lower than you anticipated or think is fair.
• The prescription drug you have been taking for MS is moved to a different tier, and so the out-of-pocket costs you will have to pay for the drug will increase if you continue taking it.

Talk With Others Who Understand

MyMSTeam is the social network for people with multiple sclerosis and their loved ones. On MyMSTeam, more than 167,000 members come together to ask questions, give advice, and share their stories with others who understand life with multiple sclerosis.

Do you live with MS and have experience filing a health insurance appeal? Share your experience in the comments below, or start a conversation by posting on your Activities page.