How to navigate the healthcare appeals process

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by GET JESSE / KING 5

KING5.com

Posted on November 8, 2013 at 12:24 AM

Updated Friday, Nov 8 at 12:28 AM

Appealing a health insurance denial can be difficult.  It's especially so for Robert Mitchell, a victim of prostate cancer who wants a drug called Tykerb.

"It's $3,800 a month," said Mitchell.

Mitchell's insurer, LifeWise, denied his first claim because the drug is experimental.

"I've been paying for it for about a year now, out of my own pocket, along with the rest of stuff you have to pay for with cancer," said Mitchell.

Robert and his physician went to work, trying to prove that Tykerb is appropriate in this case.

"We've been controlling my cancer for over a year now using this drug cocktail.  When we take this drug away, the drug cocktail doesn't work," explained Mitchell.

It took more than the 60 days the insurance company allowed to gather information for a second appeal.  So he was denied again.

"What am I going to do when I run out of money?  What am I going to do when I run out of money?" asked Mitchell.

Mitchell called me and I contacted Eric Earling with LifeWise.  Earling said there are exceptions to the 60-day rule.

"Such as if there is additional medical information that needs to be gathered," explained Earling.

Insurance Commissioner Mike Kreidler wanted to remind patients they have the right to an independent review board appeal.

"Once they've made a decision that you're not covered then you go to the independent review organization for the final appeal. There you have an opportunity with the independent board that does not have any vested connections with the insurance company to assist you in doing a thoughtful review," explained Kreidler.
 
And if you have an employer plan, you may have an additional appeal level.

"For a typical plan with employer coverage, there is an additional layer of internal review and a different set of eyes," explained Earling.

Just this week, LifeWise denied Robert's case again.  Now he's headed to the independent review board for his final appeal chance.

"We've given them enough research data to support approval.  Hopefully they'll get it right," said Mitchell.

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