Claim Denials on the Grounds that the Treatment is Experimental

Part 2, Chapter 4: Traditional Individual and Group Plans, Doctors' Bills Page 20

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Claims may occasionally be denied on the grounds that a particular treatment or test is experimental. My experience suggests that there may be times when a new treatment or test is viewed as standard medical practice by a provider, but may be viewed as experimental under the terms of some insurance policies. In some cases, a claim appeal that includes a letter from a provider or from the local medical society specifying that the treatment or test is considered standard medical practice -- assuming that is the case -- may be sufficient to persuade an insurance company to review it's earlier determination.

However, it's important to remember that reimbursement is generally based on procedure codes. Thus, even if an insurer agrees to provide coverage for a new test or treatment in response to a claim appeal, it may take a while until a new procedure code can be established. In the meantime, reimbursement may be provided on the basis of a related procedure code. That may result in a significantly lower payment.

If that occurs, you can ask your doctor and/or the local medical society to work with the insurer to help develop a new procedure code so that payment can be made at the appropriate level. Once the new code has been established, you may need to file a claim appeal to obtain appropriate reimbursement.

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