Making Your Case

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Volume 19 · Issue 5 · September/October 2009 | Download PDF

by David McGill, Chair, Amputee Coalition Board of Directors

Understanding the Basics of a Successful Appeal Letter

Making Your Case 01Insurance companies spend significant resources in drafting detailed medical policies and clinical guidelines that support their denials. More often than not, these policies are clearly written, organized and backed by evidence. If you want to overturn a decision based on those guidelines, you must fight back with thoughtful, well-crafted appeals that incorporate these five basic rules.

1. Understand the “why”

When you receive a denial, your first job is to figure out why the insurer refused to pay. Do not overlook the importance of this step. If you can’t successfully do this, you have almost no chance of winning. Fortunately, this isn’t as complicated as you might think. In most cases, insurers deny a claim for one or both of the following reasons:

  • The device “isn’t medically necessary”
  • The device is “experimental/investigational.”

Read the denial letter carefully, looking for these phrases. If you don’t understand why your claim was denied, ask your prosthetist for help. You should never try to write an appeal until you have completed this step. Otherwise, you’re like a skydiver without a parachute: You can jump out of the plane successfully, but the landing will be a real downer.

2. Follow the 30-second rule

Perhaps the biggest mistake people make when drafting an appeal is starting with a detailed history of how the claim has proceeded up until that point. Look at it this way: If you met your friend to hear her talk about her climb up Mount Everest, would you enjoy spending the first 20 minutes listening to her mind-numbing description of the fabric on the seats of the airplane that flew her to Nepal?

Get to the real issue(s) within 30 seconds of the reader picking up your letter. Does the insurer claim that your prosthesis isn’t medically necessary? Immediately state that “The insurer argues that this device isn’t medically necessary, but there are three facts that disprove that claim.” The insurer claims that your prosthesis is experimental/investigational? Immediately note that “While the insurer contends that this device is experimental, the following facts demonstrate otherwise.”

The person reading your appeal likely knows little about prosthetics, and equally important, knows nothing about your case. The reader wants guidance, and is looking for the issues. When you state them up front and highlight the facts supporting your arguments, you’ve achieved a big initial “win” – you’ve framed the entire discussion around which the appeal will be evaluated. In contrast, if you fail to do this, the reader will frame those issues the way he or she sees fit, often to your disadvantage. Again, an example is illustrative.

If you go to your prosthetist and generally complain of discomfort, he or she will try to figure out what the problem is. But without specific guidance from you, you force your prosthetist to frame the issue – your discomfort – in his or her own terms, which may be entirely different from what you’re actually experiencing. On the other hand, if you say that your above-knee prosthesis rotates inward after 5 minutes of walking, you have framed the issue with clarity, and the prosthetist can now troubleshoot based upon the problem you’ve identified.

Writing is no different. Your job is to explain to the reader what the issues are and why your position is right. This can be a little scary. Most of us learn to avoid taking clear written positions in school because you get a bad grade if the teacher decides you’re wrong. Yet, when writing an appeal, your best chance of success lies in stating the problem clearly and quickly, and explaining why the insurer has it backwards.

3. Rank your arguments

Always lead with the strongest argument. If you’re arguing that a device is medically necessary, you may want to start by pointing out that it reduces your risk of falling by 25 percent, rather than quoting your beloved Aunt Gertrude, who says that you walk better in the new prosthesis.

This step serves two purposes. First, it helps you organize your arguments in a rational, clear manner. Second, it makes you more credible to the reader. If you can’t tell the qualitative difference between Aunt Gertrude’s statement and clinical data demonstrating the necessity of the device, why should the reader believe anything you say?

4. Provide evidence

Imagine that you’re making a closing argument to a jury: “As you all know, my client, Billy Jones, could not have possibly committed the crime he is accused of.” Then you sit down without another word. How do you rate your chances of keeping poor Billy out of jail?

On the other hand, if you said: “Billy Jones could not have possibly committed the crime he is accused of. His phone records clearly show that he was speaking to his mother at the time of the robbery. He e-mailed a picture of himself playing with his pet alligator to his mother during that same time. And before the police lost sight of the suspect in the alley behind the bank, poor Billy had checked into the emergency room with bite wounds to his face, as his alligator had objected to Billy flashing the camera into his eyes at point-blank range.”

In both scenarios, you stated a conclusion: Billy is innocent. But in the second example, you support your statements with evidence, painting a compelling picture for the jury that makes it more likely that they will side with you.

Similarly, stating in your appeal that “it is clear that the prosthesis is medically necessary” gets you next to nowhere. Showing that it is medically necessary because (1) you have a history of back pain with your old prosthesis, (2) data shows that this device reduces stress on the spine, and (3) your doctor has prescribed the device for other patients with the same complaints and has gotten excellent results gives you credibility and undercuts the insurer’s position.

Most people ignore the evidence when writing appeals. They make conclusive statements about how the device will help them without providing supporting facts. Again, this is an area where your prosthetist can and should help you. Ask why your prosthetist recommended this particular item for you in the first place. Your prosthetist should be able to make detailed and powerful arguments in support of that device.

Alternatively, if you are attacking an experimental/investigational denial, work with your prosthetist to understand issues, such as how long the item has been used in the U.S., whether other payers reimburse it, and how it is similar to other devices that have been in use for years. In short, never be satisfied with general conclusions. Dig down to that next level to reassure the reader that you’ve done your research and can back up your statements.

One final thing: attach those resources (studies, articles, medical records, etc.) to your appeal letter. When I drafted insurance appeals, I attached at least 10 to 15 exhibits, and usually significantly more than that. Yes, it was a lot of work. But those exhibits made the difference between a flashy but empty letter and a solid, substantive appeal.

5. Don’t overstep

Pay particular attention to words ending in “ly.” They add little value to your arguments. Adding words like “clearly,” “obviously” and “cannot possibly” to your arguments does not strengthen them. In fact, those words tend to do just the opposite. When I say, “Clearly, the insurance company erred when denying my claim,” I’ve added nothing to the sentence by using that first word. When I say that the insurer “cannot possibly conclude that the device is experimental,” I’ve again overstepped. Indeed, the insurer has already stated that the device is experimental, so it is quite possible to reach that conclusion, my grand statement to the contrary notwithstanding.

These kinds of phrases reflect our own insecurity about the strength of our arguments. If the point we’ve made is clear, we don’t need to say, “clearly.” Anything is possible, so instead of saying that the insurer “cannot possibly conclude x,” we’d be better off stating that “the validity of the insurer’s conclusion x is undermined by y.”

When writing appeals, your odds of winning are based on the quality of your arguments (assuming, of course, that you’ve presented them clearly). Making sweeping, opinion-based declarations is not a good strategy.

Sample Appeal Letter (Letter by Marc Rohner and comments by David McGill)

Dear Sir or Madam:

I take great issue with your handling of my claim to date. My prosthetist was informed on November 21, 2006, that my physician had “only 24 hours” to make a verbal appeal. Although it was difficult for me to reach my physician on such a short notice, I was able to get a message to him, and he attempted to comply with the “24-hour” period by making a phone call on November 22, 2006, within the mandated 24-hour time period. However, your designated contact physician was unavailable when my physician attempted to reach him, and as a result my physician was forced to leave a message for your designated physician to call immediately. Your designated physician didn’t return my physician’s call that day (November 22, 2006), nor the following day, which was Thanksgiving Day. Consequently, your mandated “24-hour policy” to make a verbal appeal is unrealistic, especially if your designated contact physician fails to adhere to this policy.

Since your designated physician failed to promptly respond to my physician’s efforts to contact him and thereby preserve my rights to a verbal appeal, I was unfairly and arbitrarily denied the verbal appeal process guaranteed by your company. Therefore, I respectfully demand an opportunity to verbally appeal this matter. Your failure to permit a verbal appeal has caused unnecessary effort and time for all parties involved, and in addition has prolonged the ordering, fitting and use of the microprocessor C-Leg for me. This delay has a direct impact on my quality of life as well as a direct impact on all who provide care and assistance to me.

My appeal is supported on several bases. The acceptance of this claim and approval of the C-Leg would benefit both me and your company for years to come. The denial letter alleges that the C-Leg is experimental and medically unnecessary. However, these statements are factually and medically invalid.

 First, I respectfully request that you promptly provide to me the data that served as the basis for you to label this product as experimental. In addition, please provide the date of issuance of this data. Contrary to your assertions,this product can not possibly be considered experimental as this prosthesis has been in use since 1997 outside of the United States, and since 1999 in the United States. Further, the Food & Drug Administration, Veterans Health Administration and Medicare do not define the microprocessor as experimental. If the U.S. government recognizes the C-Leg system as valid durable medical equipment, then there is no valid support for your company to label this product as experimental.

Further, I take issue with the qualifications of your designated contact physician. Since your company’s contact physician is a family practitioner only, this person should be required to consult specialist physicians within this field of practice; in addition, the designated contact physician should not rely on outdated literature.

I was also informed that the C-Leg is not medically necessary; this assertion is similarly incorrect. I already have a previous injury to my left ankle, which required surgical intervention in June 2003. The C-Leg can bear more weight without buckling, which will greatly assist in efforts to prevent arthritic buildup from overuse within the left ankle due to the prior mentioned trauma. Clearly, this should be a concern for your company since the C-Leg will help in decreasing the potential overuse problems in the left ankle; in essence, this will help lower future potential medical costs.

Of importance to your company and relevant to potential future claims, the C-Leg will allow me to have a more symmetrical gait pattern. Given my current age of 34, with life expectancy to the middle 80s, these features can play a vitally important role in preventing future problems. In the 2 months since my amputation, I have noticed a great deal of fatigue within my left knee due to overuse and increased ankle discomfort.

I have also chosen the C-Leg for employment reasons as well. I am a pathology assistant. This job requires a great deal of standing in one location for extended periods of time. The C-Leg microprocessor is currently the only prosthetic device on the market that can be locked in a flexed position. This will allow me to take significantly more weight off of my functional leg to further aid in preventing overuse syndrome. There are hydraulic prostheses that can be placed in a flexed position, but the problem is that they can change in the degree in which they are locked should I momentarily shift my weight, thus creating instability and great potential for accidental injury.

Finally, I am attempting to obtain the data that was used as stated in my denial letter, which is both within my right to receive, and is necessary for my efforts to appeal your recent denial of my claim. Due to the lack of cooperation by your employee(s) in providing this information to me in a timely fashion, please note that I respectfully reserve the right to further supplement this appeal process, once I have had an opportunity to receive and review all of the relevant information upon which you have denied my claim.