I have surgery scheduled in 10 days, but my insurance (Harvard Pilgrim) denied coverage, saying it’s not medically necessary. They claimed I hadn’t tried two treatment options first. One of those treatments was something I had already tried on my own, but I never mentioned it to my doctor, so it wasn’t documented. After the denial, I completed the second treatment option, though I knew it wouldn’t work due to the complexity of my condition. My doctor filed an appeal last week, but they said it could take up to 30 days for a decision.
Is there anything I can do to push for a quicker decision given how soon my surgery is? I’ve had multiple procedures for this issue in the past with other insurance plans, and I’ve never had a denial for something so necessary. I feel overwhelmed. Any advice?
If this is an urgent situation, your doctor might be able to request an expedited appeal. Usually, this is allowed if waiting for a standard appeal could seriously harm your health. You or your doctor should contact the insurance company and ask about this option as soon as possible.
Did your doctor request a peer-to-peer review? This is when your doctor speaks directly with an insurance-appointed doctor to explain why the procedure is medically necessary. It can sometimes speed up the process if done promptly. If your condition is worsening, your doctor might also be able to justify an expedited review.
Ask your doctor to submit an urgent appeal request if your condition could deteriorate without timely treatment. Insurance companies are required to review urgent appeals within a few days. Make sure your doctor includes documentation showing why the surgery is time-sensitive.
In my experience, calling the insurance company directly and explaining your situation can sometimes help. Let them know your surgery is scheduled and ask if they can expedite the appeal. Be polite but persistent, and ask your doctor’s office to follow up too.
You’re not alone in dealing with this kind of frustration. Keep all your documentation ready and stay in touch with your doctor. They’re your biggest advocate in this process. Expedited appeals are your best bet for getting a quicker decision.