Health insurance denials can be stressful, especially when the reason given is that a treatment or service is “not medically necessary.” This type of denial is familiar with major insurers like Anthem Blue Cross and Blue Shield of California. While these denials can be frustrating, there are steps you can take to appeal the decision and advocate for the care you need.
Understanding a “Not Medically Necessary” Denial
When an insurer claims that a treatment is not medically necessary, it means they do not believe the treatment is required based on the patient’s diagnosis, medical history, or available guidelines. Too often, insurers deny coverage for procedures, therapies, medications, or surgeries that your doctor considers essential for your health.
It’s important to remember that a denial does not mean you are not entitled to care. Insurers may rely on rigid policies or outdated information when making coverage decisions. Appealing the denial can help ensure you receive the treatment recommended by your healthcare provider.
Steps to Appeal a Denial
1. Review the Denial Letter
Start by carefully reviewing the denial notice from Anthem Blue Cross or Blue Shield of California. The letter should include the reason for the denial, the specific policy provision being cited, and instructions for submitting an appeal. Take note of any deadlines, as appeals must be filed within a certain timeframe to be considered.
2. Gather Supporting Documentation
Collect all relevant medical records, test results, and letters from your healthcare providers that explain why the treatment is necessary. Documentation that outlines your diagnosis, treatment plan, and potential risks of delaying care can strengthen your appeal. The more evidence you provide, the clearer it is that your treatment is medically required.
3. Submit an Internal Appeal
Both Anthem Blue Cross and Blue Shield of California allow policyholders to submit an internal appeal. This process involves sending a formal written request for review along with supporting documentation. Make sure your appeal is clear, concise, and addresses the reasons the insurer provided for the denial. Request that the denial be overturned so you can access the care you need.
4. Consider an External Review
If your internal appeal is denied, you may have the right to request an external review. This involves an independent third party reviewing the insurer’s decision. In California, this is often facilitated through the Department of Managed Health Care or a similar regulatory agency. External reviews provide an additional opportunity to have the denial reversed.
5. Seek Legal Guidance
Health insurance appeals can be complex and time-sensitive. Engaging an attorney experienced in health insurance denials can help you navigate the process, ensure deadlines are met, and advocate effectively on your behalf. Attorneys can also identify any bad faith practices by the insurer and take further action if necessary.
Taking Action
A “not medically necessary” denial doesn’t have to prevent you from getting the care you need. By reviewing the denial, gathering evidence, and submitting a well-documented appeal, you improve your chances of having the decision reversed. Too often, insurance companies deny coverage for treatments that are clearly necessary, and professional guidance can make a meaningful difference.
Los Angeles Medical Necessity Denials Lawyer
If you or a loved one has been denied coverage by Anthem Blue Cross or Blue Shield of California, The Law Offices of Scott Glovsky can help. With decades of experience navigating health insurance denials, we guide clients through the appeal process, ensuring their rights are protected and their care is not delayed.
Contact us today at (626) 323-8351 for a confidential consultation to discuss your situation and explore your options for getting the treatment you need.