By: James

James — Wed, 05 Aug 2009 21:27:16 +0000

I badly need orthognathic surgery(which is a procedure generally covered by medical, not dental insurance) due to my nearly 3/4″ underbite, but both the claim I filed 3 years ago and the one I filed recently were denied. I am 19 and still under my Mom’s coverage, which she gets from her company. The insurance is Aenta, but it’s her employer, L3 communications, that specifically excludes orthognathic surgery from the company plan. Can the appeals process described above apply the same for my Mom’s employer, or is it strictly an insurance issue? If anyone has any insight it would be greatly appreciated.

By: Irene

Irene — Thu, 17 Apr 2008 00:25:19 +0000

Wow.

By: Dennis

Dennis — Mon, 30 Jul 2007 04:24:35 +0000

I agree with you on this. I have Cigna as my primary insurance provider. My wife has been seeing a doctor (MD) that is out of network and is also on occasions using some so called Cigna branded experimental treatments (at least in this country-most of the treatments are standard in Europe). The doctor is one of the only ones (out of about 6 we have seen) in the city we live that is effectively treating her. We have had to appeal Cigna’s denials for several claims. It seems that when a claim is sent in they manually key it in and then the computer goes to work and performs an automated claim scan for anything that is “non-standard”. If it finds anything it generates a denial. It then takes an appeal to get a human to review the same computer claim info and make another decision on it. It definitely pays to pursue it and be terse in your appeal letters and tell them what you want and why you should have it. They have actually covered experimental treatments as a result of an appeal we filed that they have written coverage positions on (like their 14 page salivary hormone testing paper). Don’t let that stop you because if you can show them why in the patient’s individual case it is needed they will cover it. Cigna “brands” a doctor/provider as experimental if any claim comes through with an experimental procedure on it. The doctor is then “red flagged” (as they call it) and all future claims for the doctor/provider will be denied even if you are only submitting an office visit. It takes an appeal to “reset” the “red flag” to “green”. But if you send another batch of claims through that have an experimental procedure on it will then “red flag” them again and thus another appeal, etc. to clear it. This has been happening to us and thus we are now getting a family attorney involved to try to keep the “red flag” a permanent “green”. A little extreme since attorneys are expensive and definitely not a “fivecentnickel” move but if you have one in the family see if they can help out. So anyway, this is specific to Cigna I guess but it is FYI info to go along with your denial/appeal info.

Comments on: Appeal Your Health Insurance Denials

By: James

By: Irene

By: Dennis