Not a covered benefit

A plan denies a service as “not a covered benefit” when it says its contract does not include the service at all. That is different from saying the service was not needed, or was coded wrong, or was done by the wrong provider. Because it is a question about the contract, your best tools are the plan document and, where they apply, laws that require coverage.

What this means

The plan document (for an employer plan, the summary plan description or the certificate of coverage) lists what the plan covers and what it excludes. Common examples: cosmetic procedures, dental or vision care in a medical plan, services during a waiting period, custodial care, and services above a stated limit. The denial notice must name the plan provision it relied on.

Be realistic about outcomes. FAIR Health, a nonprofit that publishes insurance information, warns that a service the plan simply does not cover is unlikely to be won on appeal. The Kennedy Forum, a mental health policy organization, notes that pure coverage (contract) disputes are generally not eligible for external review. Federal external review lists denials involving medical judgment, denials that turn on whether the No Surprises Act protections apply, and rescissions. An eligibility finding, such as a finding that you are not covered at all, is not eligible. But some “not covered” denials do turn on medical judgment, and the independent reviewer decides whether that is so. For example, the federal rule treats as reviewable an out-of-network denial where the plan covers out-of-network care if the service cannot effectively be provided in network.

When the law requires coverage. Some rules require coverage even if the plan document does not list the service. The first two apply to plans that are not grandfathered:

• Preventive services. Services rated A or B by the United States Preventive Services Task Force, recommended immunizations, and specified preventive care for children and women, without cost sharing.
• Clinical trials. Routine patient costs in an approved clinical trial, and participation in the trial.
• Mastectomy reconstruction. A plan that covers mastectomy must cover all stages of reconstruction of the affected breast, surgery on the other breast for symmetry, prostheses, and treatment of physical complications including lymphedema. This applies to plans that cover mastectomy.
• Childbirth stays. At least 48 hours after a vaginal delivery and 96 hours after a cesarean section, unless the attending provider and mother decide on earlier discharge.
• Emergency services. Without prior authorization, in or out of network.
• Medicare Advantage. A plan must follow Original Medicare’s coverage rules and may not deny basic benefits using criteria that are not in those rules.
• Medicaid for people under 21. The state must cover medically necessary services to correct or ameliorate a condition, whether or not the state plan covers them.

What to do

1. Read the denial for the provision. Find the exact words the plan relied on. (You.)
2. Get the plan document. Ask in writing for the plan documents, not only the summary. Use the plan documents request letter. (You.)
3. Compare the wording with your service. Does the exclusion actually describe what you had? Look for definitions. A different code for the same care can change the result, so ask the billing office whether the service was coded correctly. (You and the billing office.)
4. Check the protections above. If the service falls within one, name it in your appeal. (You.)
5. Look for exceptions in the plan’s own words. Read the definitions and any exceptions listed under the exclusion. The guide on using the plan’s own words shows how. (You.)
6. Appeal in writing. Use the not a covered benefit appeal letter. State what you had, quote the exclusion, and explain why it does not apply or why the law requires coverage. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial. Check the date on your notice, which controls. (You.)
7. If you are in a self-funded employer plan, ask the employer. The employer decides what the plan covers, and may be able to make an exception. The employer plan sponsor request letter and the guide on asking an employer to overrule explain how. (You.)
8. Ask the provider about the rest. If an exclusion stands, ask the provider about a lower price or a payment plan. (You.)

What the plan may say, and what to say back

“This service is excluded under your plan.” Ask for the plan language and the date of the document. Ask whether the exclusion applies to the diagnosis and code you were billed.

“This is cosmetic.” If the service treats a condition, ask your doctor to explain the medical purpose. If it is breast reconstruction after mastectomy, the law requires coverage for plans that cover mastectomy.

The rule

A plan that covers mastectomy must cover all stages of reconstruction of the affected breast, surgery on the other breast for symmetry, prostheses, and treatment of physical complications including lymphedema. 29 United States Code (U.S.C.) 1185b

Watch for

• Time versus odds. If the exclusion is clear and no law applies, an appeal may not change the result. See the guide on whether an appeal is worth it. A complaint to the regulator is still possible.
• Grandfathered plans do not have the preventive services or clinical trial rules.
• Short-term and similar plans may exclude broadly and fall outside the Affordable Care Act appeal rules.

What next

• Get your plan documents: how to ask for the full plan.
• Use the plan’s own words: find wording that helps.
• Is it worth appealing?: weigh the odds and the effort.
• Ask your employer to overrule: when the employer runs the plan.