How to appeal an insurance claim denial for MS treatment

Learning that your insurance company refuses to cover your multiple sclerosis (MS) treatment can feel devastating, especially when the out-of-pocket cost is high.

But before you give up hope, keep in mind that you have the right to appeal your insurer’s decision.

While the thought of appealing a claim denial may seem overwhelming, particularly when you’re already dealing with a chronic condition, it may be worth your time and energy. It is possible for a decision to be overturned.

Understanding some of the reasons for denials and strategies to appeal them can help you feel more confident and supported throughout the process.

Why your claim may be denied

An insurer may deny a claim for an MS treatment for various reasons, ranging from their interpretation of medical necessity to issues with prior authorization.

Examples include:

• medication deemed experimental or investigational
• insurer says treatment is not medically necessary
• problems with prior authorization, such as missing forms or incomplete paperwork
• required supporting documentation not submitted with claim
• insurer says step therapy requirements were not met
• treatment not on the insurer’s formulary, which is the list of prescription medications that an insurance plan covers or prefers

You should receive a letter from the insurer that explains why they denied coverage. Read it carefully and make sure to research and understand the stated reason or reasons before appealing.

How to appeal a denial

Appealing a claim denial requires careful adherence to the rules mandated by your specific insurance company and, often, a good deal of persistence.

Jill Blackburn, president of the Pediatric Multiple Sclerosis Alliance, has extensive experience fighting insurance denials because she dealt with them after her daughter was diagnosed with MS in 2012 at the age of 15. These days, she draws upon that experience in her work for the organization to help others navigate the insurance appeals process.

If your insurer has denied coverage, Blackburn recommends that you first notify your doctor so they can start the appeal process. You should also contact your insurance company and ask if you can file your own appeal.

Blackburn stressed that reaching out directly to your specific insurance company is essential because different companies have different rules and requirements regarding appeals and related documentation.

For example, when she appealed a denial of her daughter’s MS medication — which was not approved for children at the time — she was also required to submit two papers from peer-reviewed journals that supported the medication’s off-label use in children.

“I submitted five,” she says. “I figured more is better. And [I] just kept calling, kept checking.”

Eventually, her persistence paid off and the company allowed coverage of the medication.

Other tips for navigating appeals:

• Review your policy: Read your insurance policy or summary of benefits and check what it covers.
• Ask for a patient member advocate: When you contact the insurance company, Blackburn says, ask to be connected to a patient/member advocate, who can assist you with the process.
• Document everything: Start a folder and an “appeals diary” to document what you have done and when as part of the appeal. Keep notes with the dates from your calls, as well as emails and any other communications with the insurer.
• Don’t hesitate to be the squeaky wheel: “Sometimes if you’re knocking on someone’s door constantly, they just want to take care of it so you stop,” Blackburn says.
• Consider external reviews: Inquire with both your insurer and your state’s health department about the rules and deadlines for filing a request for an external review, which is handled by an independent third party.
• Talk to a lawyer, if needed: If you encounter obstacles that may be difficult to tackle on your own, consider getting guidance from an attorney who specializes in health insurance. Many offer a free initial consultation.

Lastly, Blackburn highlights the importance of not giving up.

“Keep trying,” she says. “Reach out to everybody. At some point, someone may know something that’s going to help you achieve success.”

Additional considerations

There are other related challenges that you may encounter during the appeals process.

Depending on your exact circumstances and symptoms, you may have to find a way to pay for the medication as you wait for a decision from the insurer.

If that’s the case, you can contact the drug manufacturer and inquire about their patient copay and financial assistance programs. You can also reach out to other organizations, such as the PAN Foundation or the Assistance Fund, for help with paying for treatment.

You may also want to prepare for the potential impact of the denial and the appeals process on your emotional well-being. Appeals often take time, and the uncertainty of whether you will have coverage can be very stressful.

Turning to MS peers for support can be invaluable, especially if you find others who have faced similar situations.

Connecting through a support group, such as the Multiple Sclerosis News Today Facebook group, can be a way to surround yourself with people who will not only empathize with you but may also provide practical, meaningful advice.

As challenging as appealing a claim denial can be, taking action can make you feel more empowered. Armed with the right information and supporting evidence, you can confidently advocate for your well-being and MS treatment needs.

Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.