Not medically necessary
This type of denial places follow-up squarely on your provider, but I always encourage the patient to get involved. Insurance companies are essentially business people who follow general medical guidelines to manage the beneﬁ t process. The medical director of the insurance company is the only person who really makes medical judgments and he or she only reviews several dozen appeals each day.
The fact that you received this type of notice means that something about your treatment did not ﬁ t into the general policies programmed into the insurance company’s claims system and the medical director has probably not seen it. These general policies are actually standardized across all insurance companies. They are called the Milliman’s Medical Underwriting Guidelines and they are probably available on your insurance company’s website. If they know what they’re doing, your provider will ﬁ nd out which guideline is causing a problem and then issue an appeal that addresses the guideline as it relates to the uniqueness of your treatment.
If a treatment or device is approved by the Food & Drug Administration (FDA), generally the insurance companies will cover it as well. The insurance companies do not test the effectiveness of devices or treatments. They wait until there is sufﬁ cient research from medical colleges and universities and the FDA to make their coverage decision. After that point, it is up to your employer to decide whether it is to be included in your beneﬁ t plan. I’m not taking sides, but I would venture to say that new, cutting-edge treatments and drugs are most often not as effective for the patient as the traditional treatments. Don’t misunderstand me, there are deﬁ nitely legitimate advances, but they represent a minority, not the majority of experimental treatments. Studies can be manipulated and side-effects may not be worth the beneﬁts.