Health Insurance Denial: How to Appeal

Immunoglobulin (IG) therapy is an expensive therapy. Unfortunately some insurance companies deny IG therapy for primary immunodeficiency, until the insurer understands the rationale behind this expensive life sustaining therapy. They are very reluctant to approve expensive payments per year where indications are not substantiated.

Below are some “how to” tips from a clinical immunologist that has been successful in overturning IG denials, followed by some additional helpful information, including a link to sample appeal letters that should be tailored to the patient’s clinical history:

• The appeal should be short, succinct & carefully documented.
• Keep in mind that you have 2 minutes of the Medical Director’s attention.
• Provide well-accepted diagnostic studies which are in the practice guidelines.
• Provide standards of practical criteria to support the laboratory studies.
• Provider proof and documentation of serious infections/complications which have not been responsive to appropriate medical/surgical intervention; including clear radiographic evidence of persistent disease, e.g. lungs, sinuses et al, clinical documentation of infections etc.
• Focus on the rationale for immunoglobulin therapy – a doctor’s letter that states “because it is medically necessary” is not specific enough to be added to an appeal letter. Precise statements are required. . . for example: 3 episodes of pneumonia with fever to 102. Chest x-ray (if available) showed lobar pneumonia and xx days of antibiotics were required.
• Keep in mind that the insurance companies are reviewing thousands of appeals; therefore, the larger packets, will be put to the side. The shorter the appeal, the shorter the turn-around-time for a response.
• When concluding the letter, add the names of the immunologists that have completed the scientific research on the diagnosis in question, should the insurer request a peer review. For example “Should you have any questions, I would request a peer review by either Dr. John Smith or Dr. Ann Jones from the University School of Medicine”

For additional information:

1. To view Sample Appeal Letters and References CLICK HERE
2. Additional References to attach to appeal letter can be found at www.pubmed.com (PubMed is a service of the U.S. National Library of Medicine that includes over 18 million citations from MEDLINE and other life science journals for biomedical articles back to 1948.)
3. The IDF Consulting Immunologist Program offers free physician to physician consults; consults or second opinions on issues of diagnosis, treatment and disease management; and access to a faculty of recognized leaders in clinical immunology 1-800-296-4433.
4. IVIG Toolkit: The AAAAI Primary Immunodeficiency Diseases (PID) Committee has created an IVIG toolkit to educate payers and regulators who are responsible for coverage determinations, and aid physicians in the safe, effective and appropriate use of IVIG for patients with primary immunodeficiency diseases. The IVIG toolkit includes:

• Eight guiding principles for safe, effective and appropriate use of IVIG (PDF)
• Guidelines for the site of care of the administration of IVIG therapy for patients with PID (PDF)
• AAAAI Work Group Report: The Appropriate Use of Intravenously Administered Immunoglobulin (IGIV) (PDF)
• “Use of intravenous immunoglobulin in human disease: A review of evidence by members of the primary immunodeficiency committee of the American Academy of Allergy Asthma & Immunology,” published as a supplement to The Journal of Allergy and Clinical Immunology in April, 2006 (PDF)
• Letter to contract and medical directors to advocate for the coverage of IVIG (PDF)

The IVIG toolkit has been approved by the AAAAI Board of Directors, and endorsed by the Clinical Immunology Society (CIS) and the Immune Deficiency Foundation (IDF).
http://www.aaaai.org/members/resources/initiatives/ivig.stm

Appeals Process – slides presented at the IDF 2011 National Conference