How to Write an Effective Appeal

Receiving a prior-authorization denial is an extremely deflating event. You have already expended effort to evaluate, determine the best course of action, and submit the request via the insurer’s processes, only to hit this roadblock. What do you do now? Gather Background Information There are five essential pieces of information to effectively address a prior-authorization denial. Evidence of insurance coverage Obtain a copy of the patient’s insurance card. Be aware of whether the plan is commercial, Medicare, Medicaid, self-funded, or workers’ compensation, etc. Different regulations and processes apply depending on the type of coverage. In some cases, a payer may not require prior authorization and therefore there is no appeal process available (even if you request a predetermination). This is a significant hurdle because internal reviewers are often restricted from overturning denials, and an appeal must progress to external review to garner approval. In these situations, the provider and patient must decide whether they will assume the risk and deliver the service and pursue a post-service appeal. A complete copy of the information submitted for prior authorization Analyze the documentation that was submitted. Does the request clearly identify the service being requested? Does the request give a complete clinical picture? Particularly in complex cases, it is important to review the authorization submission with fresh eyes. When a patient is well known to the clinician, and the care has been long term, key coverage information may not have been repeated in the most current submitted notes. This results in an incomplete clinical picture for the reviewer. A complete copy of the denial Review the denial notice and determine the deadline for appeal and where and by what method the appeal needs to be sent. For efficiency, next determine whether the member/patient will need to sign an appointment of representative in appeals form to allow you to appeal on his or her behalf and determine if there are any other plan-specific forms that may need the patient’s signature (e.g., an appeal form or complaint form). Most insurers require these instructions be included in a denial, however, sometimes they are sent only to the member. You can ask the member to send you a copy of the denial, or you can find the appeal process in the certificate of insurance. Confirm that the service described in the denial is the same service requested. Did the reviewer deny a myoelectric prosthesis when a body-powered one was requested? O&P services include more codes than other types of services, and too often a denial will result because the reviewer did not understand what was being requested. O&P technology is constantly evolving and is infrequently received (compared to other claim types) by insurance reviewers. Therefore, their knowledge and experience with the technology is likely to require them to resort to research. The relatively limited volume of O&P research increases the chances the reviewer will arrive at an unfavorable or inaccurate conclusion. I have seen wrong coverage policies applied, outdated research applied, and just plain ignorance, as in a recent denial where the reviewer claimed a prosthesis was not necessary because it was a nondominant limb. Take note of any information in the denial that identifies materials the plan reviewer applied to make the determination and collect copies of them. Excerpt the reason for the denial in preparation to respond to that issue directly. Insurer’s medical/clinical coverage criteria/policy guidelines Search the patient’s insurer website as specified on their insurance card: Find any guidelines identified in the denial that were used to make the determination Identify any appropriate guideline that should be considered. Depending on the denial reason, you may need the insurer policy on medical necessity or experimental/investigational (not all insurers have this) Then, evaluate whether the reviewer applied the correct policy or coverage guidelines in making the determination. One reviewer, in the absence of locating any applicable policy for prosthetics, recently applied official disability guidelines by Milliman Care Guidelines for arthroplasty/joint replacement as the rationale that prosthetics are not an appropriate treatment. There is not much chance of a correct conclusion when an inappropriate guidance is applied, and there is clearly an argument for appeal here. Next, evaluate whether the documentation submitted meets coverage requirements. Can you excerpt the information from the submitted records that a reviewer should consider to answer each element of the coverage requirements? Clinicians tend to believe that if a service is medically necessary for a patient, then it will be covered by insurance. This is incorrect and is the origin of many denials and recoupments. Being patient-centered, clinicians naturally tend to focus their documentation on what patients need to treat their conditions. Both physicians and prosthetist/orthotists are sometimes deficient in elaborating on why they are determining this is the appropriate treatment plan. Answering the why is an important part of meeting coverage requirements. For example, in the case of replacing a custom AFO within the reasonable useful lifetime of a same or similar orthosis, it is critical that the physician discusses the change of condition that necessitates the need for the replacement as well as specifying the reason a prefabricated brace could not be used or the reason a custom-fabricated brace is required. Many denials happen because the physician specifies a custom-fabricated brace but does not elaborate why. Clinicians are also often deficient in awareness of the coverage criteria required for the patient’s insurer to allow coverage. Can you encourage your clinicians to review documentation requirements in medical policy before they perform the in-office evaluation? Could practice intake processes include attaching the payer’s medical policy to the chart when the appointment is made, and insurance information is obtained? If documentation is found to be lacking to support a coverage requirement, address the shortcoming and resubmit additional information with the appeal. If necessary, a follow-up office visit can be set to document the additional information required. Alternatively, a physician can amend a note where the need for the service was discussed or established with any additional information that needs physician clarification so that coverage requirements are met. A copy of the patient’s certificate of insurance The certificate of insurance is the contract between the payer and the insured that details what is covered under the plan. It is the definitive source for coverage and supersedes any payer medical policy in the event of a conflict. The document is typically available to the member via the member login area of the insurer’s website. Often, when patients call their plan to request this, they instead receive a certificate of creditable coverage, which is a document to prove they had active insurance in a specific period. The document may be called different names by different payers, but is commonly referred to as a benefit booklet (not to be confused with the enrollment materials employees are provided to assist in their insurance plan selection), plan benefit summary, or summary plan description. You may prefer to receive a digital version because it is typically 100 pages or more. If the denial did not outline the appeal process, you will find it in this certificate. Check the certificate for coverage of the service requested (Look for coverages>prosthetics/orthotics, as appropriate). If the language specifies there is coverage, you will present this in the appeal. Check the certificate for exclusions that might apply. Sometimes your denial reason will say coverage is excluded because the service requested is deluxe. There is typically no language in the certificate to support this denial reason so you may find an argument to combat the denial here. Check the certificate for definitions of medically necessary and experimental/investigational if that was a reason for the denial. If the denial was for medical necessity, you can use their definition to show why the service requested meets their definition. If the denial claims the service is experimental/investigational, you will use the definition to show why the service is not experimental/investigational. This may require some research for peer-reviewed sources to support your claims but is generally effective in external reviews. From the evaluation of the information submitted and the denial rationale, as compared to the plan coverage guidelines and the certificate of insurance, you will develop the arguments with evidence demonstrating that the service should be covered. Anatomy of the Appeal Appeals tend to have many pages and reviewers might not read the full content, so it is important to organize your information with a table of contents or divider pages that make it easy to search for the information they want to see. Appeal form(s) Appeal rationale cover letter anatomy (This is the part you want to be sure they read!) Date Address to submit appeal Member/service information Salutation Paragraph 1: As the provider of services appropriately appointed by the member to represent them in appeals, we are in receipt of the denial dated XX/XX/XXXX and are submitting this appeal within the required XXX-day timeframe. Paragraph 2: Restate the denial reason Paragraph 3: Explain why you disagree with the denial—present your evidence Paragraph 4: Explain how the case meets medical necessity and coverage documentation requirements Conclusion: Request the plan review the attached and overturn the denial Signature: By the appointed representative Appointment of representative form Denial letter Physician orders Physician records (including occupational and physical therapists) Orthotist/prosthetist records Proof of delivery Advance beneficiary notice (if required) Research or product information The goal is to overturn the denial, but realistically, the plan may have procedures in place that force the appellant to go through the entire internal appeal process to get to external appeal, where they have a better chance of success. If new objections are raised in first-level appeal denials, you should address them via this same procedure. Additional Guidance Since new information is not generally included in external appeal reviews, it is important you are very thorough in the second-level appeal. This effort will make the preparation for external review less time-consuming. Typically, you will simply submit the External Appeal Request Form to the plan along with their second-level appeal decision and a copy of the second-level appeal they already reviewed. If you need to submit additional information at this stage, the plan has the right to do another internal review. Take care to resend all the information directly to the external reviewer when invited to ensure they have received complete information from the plan. All appeals should be sent via a trackable method (certified mail, for example), and even if you have fax confirmation or certified mail receipt, it is important to phone and follow up to receive the payer’s acknowledgment they have received the appeal. This allows you to verify you have sent the appeal to the correct address. The only instance you need not follow up in is if you receive a written acknowledgment of receipt from the plan. Using this method prevents unnecessary delays in getting your appeals through the process. Keep up the good fight! Susi Ebersbach, MT (ASCP), MBA, provides independent consulting and has over twenty years of experience in O&P reimbursement topics, working with both providers and manufacturers.

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