My advice for anyone fighting a worthy appeal is to take that appeal to the highest level possible.  Subscriber Assistance Programs can assist patients in arranging formal hearings with insurance companies to resolve disputes.  Each insurance company will have a specific appeals process.  It's crucial to retain all insurance correspondences during the appeals process and patients/providers need to follow these appeals processes carefully.  One misstep could put the entire appeal in jeopardy.

Some common mistakes made during the appeals process are:

• Not documenting phone calls.  Patients/providers should always obtain the first and last name (or last initial) of the insurance representative and, if possible, obtain a reference number for the telephone call.  When an insurance representative creates a reference number for a telephone call, that representative is detailing what took place during that conversation.  Make sure to review the information detailed in the reference number, particularly any instructions provided by the insurance representative.   
• Misplacing written insurance correspondence.  If an insurance company provides a determination that conflicts with early written correspondence, that determination can easily be disputed.  I once had an insurance company re-review a previously approved pre-authorization and determine that a microprocessor knee was not medically necessary.  Because we had a written insurance approval, we were able to successfully appeal this denial.  Of course, a verbal or written insurance authorization is never a guarantee of payment.  However, proof of misleading information from the insurance company is perfect ammunition for an appeal.
• Missing deadlines.  Many insurance companies will outline the amount of time allowed to respond to each inquiry.  If a patient/provider response is not received within this timeframe, the appeal could be voided.
• Responding in an incorrect format.  For example, information should not be faxed if the insurance company asks for it to be mailed.
• Re-submitting the same documentation over and over again.  Patients/providers should always try to submit new information during each phase of appeal.  This may require additional appointments with the medical team.  New dictation from a physician, therapist, and prosthetist is always helpful because it is more difficult for the insurance company to uphold the original decision.
• Not sending mail certified.  It's way too easy for an insurance company to claim that the information was not received within the required timeframe.  Send the mail certified.
• Not understanding the reason for denial.   When I fight a denial I like to fantasize that I'm preparing for a big court trial.  In order to successfully argue against an insurance company, understanding the logic behind the denial is crucial.  Denials can be made for many reasons, including lack of medical necessity or benefit plan exclusions.  Get a copy of the benefit plan and study it line-by-line.  The easiest denials to overcome are the ones based on subjective reasoning.  Not medically necessary?  Says who? 

Insurance companies are banking on the fact that most patients/providers will give up during a drawn out appeal process.  When push comes to shove, though, I think that the insurance company will ultimately adhere to the benefit guideline and approve legitimate, physician approved care.

Some useful documentation to include in an appeal would be:

• Relevant dictation from the physician, therapist and prosthetist
• A copy of the written insurance plan document, if applicable
• A letter from the patient
• Information on alternative treatments and why those may be contraindicated
• Photographs and/or video that provide a clear clinical picture
• A brief letter from a lawyer
• Any laws or statutes that may be being violated

Happy appeals!