I need more Chemo than my doctor initially thought, now my insurance doesn’t want to pay for it

During the 2012 NFL season there was a lot of controversy that surrounded one of the Monday night games on ESPN. This game was played between the Green Bay Packers and the Seattle Seahawks. During the final play of the game, Seattle’s quarterback Russell Wilson threw a Hail Mary pass toward the end zone meant for wide receiver Golden Tate. Tate and Packers defender M.D. Jennings got their hands on the ball while still in the air attempting to gain possession. The two officials near the play initially gave separate calls of touchdown and touchback. After some debate the officials ruled the players had simultaneous possession, which resulted in a Seahawks game-winning touchdown. This call led to a lot of dispute and debate between the teams, players, officials, and media. It is a controversy now known as the Fail Mary.

If you are a cancer patient and are going through chemotherapy, what would you do in a situation wherein your doctor comes to the conclusion that you need more chemo treatment than he initially thought? Ideally you would just get the treatment but you may be at the mercy of your insurance provider. If they deny you the treatment, you need to know the steps you can take to get your needed treatment. You don’t want to be left without it, so what can you do? There are many options but the one we want to look at in depth is making a claims dispute.

• Appeal a denial successfully

  •  This is the most important part of the process. You need to know what to do to be successful in your appeal. You’re going to need to collect your medical records, objective evidence, test results, labs, and doctors’ office notes to establish your diagnosis and medical necessity.

• Medical necessity denial

  •  This is really the denial of an expensive treatment or test. The insurance company may think there are cheaper alternatives. The best way to address this is to present medical records that show you’ve tried the alternatives. Another option is to prove that their alternative is not the medical equivalent. Have a letter from your doctor explaining why their alternative is not medically equivalent for you.

• Medical journal articles

  •  This helps you prove the safety and effectiveness in question. You can search for abstracts or summaries on pubmed.gov.

• Write a cover letter 

  • This needs to detail dates, how the medical journals establish your diagnosis, the treatments you’ve already tried, and how the medical articles establish the safety and effectiveness of the treatment in question. The more detailed you make this letter the better it will work for you.

If you have questions or need legal advice, please call 405-235-4500 or contact Brown and Gould, PLLC.