What if my insurance won't cover a cancer treatment?

A denial is not the end of it. You have a legal right to appeal. First inside the insurance company, then to an outside reviewer whose decision the company must obey. Most people never use that second step.

The National Cancer Institute gives the practical first move. Ask your doctor to write a letter saying why the test or treatment is needed. Send it to the insurer. If the answer is still no, use the plan's appeals process. Your hospital's billing department can walk you through the steps.

Start with the exact reason for the denial

Read the denial notice and find the stated reason. It matters, because different reasons need different answers.

Common reasons are short. The service is not seen as medically needed. Or it is called experimental. Or you are not eligible for the benefit. Or a prior authorization step was skipped. That last one is often fixed with a phone call, not an appeal.

Insurers have deadlines for telling you. They must notify you within 15 days when you seek prior authorization. Within 30 days for services you already had. Within 72 hours for urgent care.

The internal appeal, and the clock

An internal appeal asks the insurance company to look again. You must file it within 180 days, six months, of receiving the denial notice.

The company then has its own deadlines. It must finish the appeal within 30 days if the service has not happened yet, and within 60 days if you already received the care.

If waiting would put your life or your recovery at risk, ask for a fast-tracked appeal. Then the final decision must come as fast as your condition requires. It can be no later than 4 business days after your request arrives. The answer may be given out loud, but a written notice must follow within 48 hours.

One detail saves people grief. Send copies and keep your originals. There is one exception. The insurer wants the original request for internal appeal, plus the original form naming someone else to appeal for you. Keep your own copies of both.

External review, where the insurer stops deciding

If the internal appeal fails, an independent third party takes over. This is called external review, and your insurer is required by law to accept the reviewer's decision.

You have four months from the date of the final denial to file a written request. Standard reviews must be decided no later than 45 days after the request arrives. Fast-tracked reviews must be decided within 72 hours, sometimes sooner if the case is urgent. In an urgent case you may ask for external review at the same time as your internal appeal. You do not have to finish the internal process first.

Cost is capped. Under the federal process run by HHS there is no charge. Your plan may instead use a state process or hire an outside review group. Then you may be charged, but no more than $25.

The contact information for the organization handling your external review is printed on your Explanation of Benefits or on the final internal denial letter.

People who will do this with you

You do not have to file alone. You can name a representative who knows your condition, such as your cancer doctor, to file the external review for you.

Your state's Consumer Assistance Program can file an appeal on your behalf. A hospital social worker or financial counselor can help you assemble the paperwork, and the billing department can tell you exactly which codes were denied.

While the appeal runs, ask the hospital about a payment plan or a reduced rate so an unpaid balance does not go to collections in the meantime.

Sources

https://www.cancer.gov/about-cancer/managing-care/track-care-costs

https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/

https://www.healthcare.gov/appeal-insurance-company-decision/external-review/

https://www.healthcare.gov/appeal-insurance-company-decision/appeals/