Claim Denials on the Grounds that a Treatment is Not a Covered Health Insurance Expense
Part 2, Chapter 4: Traditional Individual and Group Plans, Doctors' Bills Page 17
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Certain treatments and services are specifically excluded by many health insurance policies. Claims for such treatments are generally denied on the grounds that they do not represent a covered expense or that they are not medically necessary under the terms of the policy. For example, many traditional individual and group policies may specifically exclude expenses related to cosmetic surgery, hearing aids, or eyeglasses.
Insurance companies want to be certain that services and treatments that are specifically excluded by a policy are not paid for by error. Thus, an insurer may occasionally request additional information or documentation before providing reimbursement for a claim that appears as if it is related to such excluded services or treatments. Thus, if your insurance policy excludes coverage for eyeglasses, your insurance company may request additional information if you file a claim that relates to medical treatment that appears to involve related eye problems. In the same way, if your insurance policy specifically excludes coverage for cosmetic surgery -- as many health insurance policies do -- your insurer may request additional information before processing a claim related to surgery of the face or nose.
In such cases, if the claim is for an expense that should be covered under the policy, all that's generally needed is to file a claim appeal that includes a letter from your doctor explaining the specific medical need for the treatment. If the treatment involved surgery, include a copy of the operative report and a copy of the hospital bill with the claim appeal. You can obtain a copy of the operative report from your surgeon, and you can obtain a copy of the hospital bill from the hospital billing office.
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