INSURANCE

APPEALING INSURANCE DENIALS FOR TYPE 1 DIABETES CARE

People with Type 1 Diabetes depend on insulin, glucose monitoring supplies, CGMs, insulin pumps and other prescriptions every single day, and an insurance denial can put access to that care at risk. Denials are common, but they are not always the final word. You have the right to challenge most denials, first through your health plan and, in many cases, through an independent reviewer outside of your health plan. The following information is intended to help guide you through the most common insurance issues that people with T1D face and how to appeal a denial. Please do not hesitate to contact us if you have any questions or need any assistance.

Common Reasons for Denials

Some of the most common coverage problems people with T1D face include:

  • Prior authorization. Your plan requires approval before it will cover a drug, device or supply, and the request was denied or not submitted.
  • Step therapy ("fail first"). Your plan requires you to try one or more different drugs before it will cover the drug your doctor prescribed.
  • Formulary exclusions and non-medical switching. The insulin, device or supply you use is not on your plan's list of covered drugs (formulary), or your plan has changed its coverage and wants you to switch to a different product for cost reasons rather than medical reasons.
  • Quantity limits. Your plan limits how many test strips, sensors, infusion sets or other supplies it will cover in a given period.
  • "Not medically necessary." Your plan has decided that the requested care does not meet its criteria for coverage.
  • Benefit category or supplier issues. Your plan covers a device under a different benefit (for example, durable medical equipment instead of the pharmacy benefit), or requires you to use a specific supplier or network.

Reading the Denial

Your health plan must tell you in writing why it denied your claim and how to appeal. Read the denial notice carefully and identify (i) the specific reason for the denial; (ii) the plan provision or clinical criteria the plan relied on; (iii) the deadline to appeal; and (iv) where and how the appeal must be submitted. You are generally entitled to request, free of charge, copies of the documents, records and other information relevant to your claim, including the clinical criteria used to deny it.

Understanding Your Type of Coverage

The rules that apply to your appeal depend on the type of coverage you have, and it is important to know which applies to you:

  • Individual, marketplace and fully insured employer plans are regulated by your state's insurance department, in addition to federal law.
  • Self-funded (self-insured) employer plans are regulated by federal law under the Employee Retirement Income Security Act ("ERISA") and the U.S. Department of Labor. State step therapy and other insurance laws often don't apply to self-funded plans. Your Summary Plan Description, your employer's human resources department, or your plan administrator can tell you whether your plan is self-funded.
  • Medicare (including Original Medicare, Medicare Advantage and Part D drug plans) has its own appeals process, described below.
  • Medicaid has its own appeals process, which includes the right to a state fair hearing, also described below.

Requesting an Exception or Override

Many problems can be resolved before a formal appeal is necessary. Your doctor can submit a prior authorization request, a formulary exception request, or a step therapy override (exception) request explaining why you need the specific drug or device that was prescribed.

Many states have step therapy laws that let your doctor request an override of a step therapy requirement. The criteria and timelines for those requests vary by state, so check with your state insurance department or review your plan documents to learn what applies to you.

Non-grandfathered individual and small group plans must also offer a formulary exception process for clinically appropriate drugs that are not on the formulary, with an initial decision within 72 hours for standard requests and 24 hours for expedited requests.

The Letter of Medical Necessity

A strong letter from your doctor is often the single most important part of a request or an appeal. The American Diabetes Association notes that documentation showing that the original drug worked makes a big difference, and that the more documentation there is proving that you need it, the better. A letter of medical necessity from your doctor should generally include:

  • Your diagnosis of Type 1 Diabetes, the date of diagnosis, and your current treatment
  • The specific drug, device or supply requested, including quantity and frequency of use
  • Why the requested item is medically necessary for you specifically
  • Any alternatives you have already tried, and why they failed or were discontinued (for example, adverse reactions, skin reactions to a device, or poor glucose control)
  • Relevant clinical information, such as glucose data, A1C results, episodes of severe hypoglycemia or hypoglycemia unawareness, hospitalizations, or emergency room visits
  • The risks to your health if the request is denied
  • A response to the specific reason stated in the plan's denial

You can also keep your own record of your glucose readings, how a new or substituted product is working for you, and any problems you experience, and share it with your doctor.

Filing an Internal Appeal

If your plan denies your request, you can file an internal appeal, which asks your plan to conduct a full and fair review of its decision. For most private health plans:

  • You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. Check your plan documents, as some plans allow longer.
  • Complete any forms required by your plan, or write to your plan with your name, claim number and health insurance ID number, and include any additional information you want considered, such as a letter from your doctor.
  • Your plan must decide an internal appeal within 30 days for a service you have not yet received, and within 60 days for a service you have already received.
  • If your situation is urgent, the plan must decide your appeal as soon as possible and no more than 72 hours after receiving it, and you may request an external review at the same time as your internal appeal.

Requesting an External Review

If your plan upholds its denial, you may have the right to an external review, in which an independent reviewer outside of your health plan decides whether the denial should stand. Denials involving medical judgment (such as "not medically necessary") and denials of treatment as "experimental" or "investigational" are generally eligible. Under federal rules:

  • You must file a written request for external review within 4 months after receiving your plan's final denial.
  • Standard external reviews must be decided no later than 45 days after the request is received, and expedited external reviews no later than 72 hours.
  • Your insurer is required by law to accept the external reviewer's decision.
  • If there is a charge for an external review, it cannot be more than $25.

If your plan is regulated by your state, your external review will generally go through your state's process, if your state has one that meets federal standards, or through a federal process. Your denial notice will explain how to request an external review. You can also contact your state's Consumer Assistance Program or state insurance department for help.

Self-Funded Employer Plans (ERISA)

If your coverage is through a self-funded employer plan, your appeal rights come primarily from federal law. You have at least 180 days to file an appeal after a denial, and the plan must provide you, free of charge, copies of documents, records and other information relevant to your claim upon request. The plan must decide an urgent care appeal within 72 hours, a pre-service appeal within 30 days, and a post-service appeal within 60 days. Plans that are not "grandfathered" under the Affordable Care Act must also provide an independent external review, and your denial notice will explain how to request it. Please note that you normally must complete your plan's claims and appeals process before you may challenge a denial in court. The U.S. Department of Labor's Employee Benefits Security Administration ("EBSA") can be reached at 1-866-444-3272 for questions about your rights under ERISA.

Medicare

Medicare Part B may cover a CGM and related supplies, such as sensors, if your doctor orders them, you take insulin or have a history of problems with low blood sugar, and you or your caregiver have had enough training to use the CGM as directed. Under Part B and Part D, the cost of a one-month supply of each covered insulin product is no more than $35, and there is no deductible for insulin. Medicare generally has 5 levels of appeal, and at each level you will receive a decision letter with instructions on how to move to the next level.

  • Original Medicare (Parts A and B): The first level of appeal is a "redetermination." You must file by the date listed on your Medicare Summary Notice, and you will generally receive a decision within 60 days.
  • Medicare drug plans (Part D): You or your prescriber can request a coverage determination or an exception. If you are requesting an exception, your prescriber must provide a statement explaining the medical reason it should be approved. If your plan denies the request, you have 65 days from the date of the denial notice to request a redetermination. The plan must decide within 7 days for a standard request, or 72 hours for an expedited request if waiting could seriously jeopardize your health.
  • Medicare Advantage plans: Your plan must tell you, in writing, how to appeal. Check your plan materials or contact your plan for details.

Free, personalized help with Medicare is available through your State Health Insurance Assistance Program ("SHIP").

Medicaid

If you are enrolled in a Medicaid managed care plan, you generally have 60 calendar days from the date on the plan's notice of denial to file an appeal with the plan. If the plan upholds its denial, you may request a state fair hearing, and federal rules give you no less than 90 days and no more than 120 days from the date of the plan's decision to do so. If your plan is reducing, suspending or stopping a service that was previously approved, filing your appeal quickly, generally within 10 days of the notice, may allow your services to continue while your appeal is pending. Check your notice carefully for the deadlines that apply to you.

Keep Detailed Records

Throughout the process, keep copies of everything, including:

  • The Explanation of Benefits forms or letters showing what was denied
  • Your appeal request and all documents you sent to your plan, such as letters from your doctor
  • Any forms you signed authorizing someone else, such as your doctor, to file an appeal on your behalf
  • Notes from every phone call with your plan or your doctor's office, including the date, time, name and title of the person you spoke with, and what was discussed

Keep your original documents and send copies to your health plan. Sending appeals by a method that provides proof of delivery, such as certified mail, return receipt requested, can also be helpful.

Sample Appeal Letter Outline

Every appeal is different, but an appeal letter generally includes the following:

  1. Your name, address, phone number, and health insurance member ID number, and, if applicable, the name of the patient (for example, your child);
  2. The date of the denial, the claim or reference number, and the specific drug, device or supply that was denied;
  3. A clear statement that you are requesting an internal appeal (or an expedited appeal, if your situation is urgent) of the denial;
  4. A brief explanation of your Type 1 Diabetes and why you need the requested drug, device or supply;
  5. A direct response to each reason stated in the denial;
  6. Any alternatives that have been tried and why they failed or were not appropriate;
  7. A list of the enclosed documents, such as the letter of medical necessity from your doctor, relevant medical records, glucose data and a copy of the denial notice;
  8. A request for a copy of the clinical criteria and any other documents the plan relied on, if you have not already received them; and
  9. Your signature and the date.

Where to Get Help

  • Consumer Assistance Programs. Many states have a Consumer Assistance Program that can help you file an appeal or a complaint. If your state does not have one, you can contact your state's insurance department.
  • Your state insurance department. If you believe your plan is not following the rules, you can file a complaint with your state insurance department.
  • Your healthcare team. Your doctor's office often handles prior authorizations and appeals and can provide the letter of medical necessity and supporting records.

If the information above does not help you resolve an issue, please contact us and we may be able to help point you in the right direction.