Insurance approved 28 days of residential and is fighting the extension. Can you appeal?
From the RecoveryHome team. We write some questions from situations people often ask us about, and answer them with general information from public health sources. Been through this yourself? Your answer could help the next person who finds this page. How we write team posts
RH
RecoveryHome team Team
asked 3 months ago
A common situation: the insurer approved the first few weeks of residential treatment, then the utilization review starts denying more days as not "medically necessary." Can families appeal, and what tends to work?
RH
RecoveryHome team Team
answered 7 days ago · general information, not medical advice
Yes, you can appeal, and it's worth doing. What tends to help:
- Ask the treatment program for a peer-to-peer review. That's their doctor or clinical director talking directly with the insurer's reviewer, with documentation of current symptoms and history.
- Get the denial in writing, including the clinical criteria the insurer used. Appeals are much stronger once the reasoning is on paper.
- Ask the program who handles utilization review. A program without a clear answer is telling you something.
- Know your appeal rights. Most plans have an internal appeal and then an external review by an independent reviewer. Ask for both the deadlines and the process.
- Ask what the insurer will approve. A denial for more residential days sometimes comes with approval for a step-down level such as partial hospitalization (PHP) or intensive outpatient (IOP). A strong step-down plan can be a good path, not a loss.
Read more: Does insurance cover rehab? · Levels of care
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