Using your plan's own words

The strongest argument in many appeals is the plan’s own language. A plan is expected to follow its own rules. When you quote them exactly and show where your records meet them, you ask the reviewer to apply the standard the plan chose. Quote, do not paraphrase, and say where each quotation comes from.

What this means

Your plan’s words appear in four places:

• The denial notice. It must state the specific reason for the denial and the specific plan provisions the plan relied on.
• The plan document. For a job-based plan, the summary plan description and plan document set out the definitions, covered benefits, exclusions and claims procedure. See how to get your plan documents.
• The clinical criteria. The internal rule or guideline the plan applied. See how to find the insurer’s medical policy.
• The claim file. The reviewer’s notes may state a reason in different words. See how to read your claim file.

GoodRx suggests quoting the plan’s own definition of medical necessity in the letter and attaching the source. The same method works for any term the plan relies on, such as “experimental”, “cosmetic” or “custodial”.

What to do

1. Write down the plan’s reason, word for word (your step). Copy it from the notice. Add the provision it cites.
2. Find that provision in the plan document. Note the document’s name, the date or version, and the page or section number.
3. Find the definition. If the reason uses a defined term, such as medical necessity, find the plan’s definition. Copy it exactly, with quotation marks.
4. Pick the version that applied. Plans change. Use the terms in effect on your date of service, and ask for any amendment. Say in your letter which version you quote.
5. Match your facts to the words. Make a two-column list: “The plan says” and “My records show”. Put each phrase of the definition on the left and the record that meets it on the right.
6. Check the exclusions. Read the list of what the plan does not cover. If the service is clearly excluded, an appeal on medical necessity will not help. Ask whether the plan has mislabelled it. A plan may say surgery is cosmetic when your records show it treats a medical condition; that is an argument about the label, based on the plan’s own definition.
7. Look for earlier approvals. If the plan approved the same treatment for you before, cite the approval by date and number. GoodRx lists citing previously approved claims for the same treatment as a tactic.
8. Put the quotations in your appeal. Use short quotations with the source in brackets, then your facts. See how to write an appeal letter that works.

What it can look like

The plan’s definition of medically necessary care is: “[exact words from the plan]” ([plan document, page X]). My doctor’s records show [fact], dated [date]. The plan’s notice says the denial was because [reason]. That reason does not fit the plan’s own definition because [one sentence].

This is a pattern. Use only words that are actually in your documents.

What the plan may say, and what to say back

“That is not how we read our policy.” Ask in writing for the provision, the page and the version the plan relies on. The notice must state the plan provisions relied on.

“That provision does not apply to you.” Ask which provision does apply, and ask for it in writing. Compare it with your quotation.

“The service is excluded.” Ask for the exclusion’s exact words. If the exclusion does not fit your case, quote it and explain why. If it does fit, an appeal on this ground is unlikely to succeed. See the page on coverage denials.

The rule

A denial notice must state the specific reason or reasons for the denial and the specific plan provisions on which it is based. See section 2560.503-1(g)(1)(i) and (ii) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.

Watch for

• The notice and the plan document disagree. If the notice cites a provision that does not say what the plan claims, quote both and ask which one the plan relied on.
• Quoting out of context. Include enough of the sentence for the meaning to be clear. Changing a quotation, even slightly, weakens your whole appeal.
• No plan document yet. Do not wait. File the appeal on time and add the quotations when the document comes. You have at least 180 days after you receive the denial notice, and your plan may allow more. Check the date on your notice, which controls.
• Other coverage. Medicare, Medicaid and other public programs have their own appeal rules and notices. See Medicare or Medicaid and children’s coverage.

What next

• How to get your plan documents: the source of the words you will quote.
• How to find clinical guidelines and studies: the evidence beyond the plan’s own words.
• How to write an appeal letter that works: where the quotations go.