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Insurance Appeals
The MAGIC Foundation, although involved only in the External Appeal Stage of a denial, realizes people may have difficulty understanding and navigating the entire appeal process when your child's medication has been denied by your insurance company. The Juvenile Diabetes Research Foundation (JDRF) has included a very good article explaining denials and appeal levels on their website (link: https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/insurance-denials-appeals/# ). This information can be applied to any medical condition and is not specific to diabetes. We hope this resource will provide you with a better understanding of an often difficult process.
In addition to the above information on general health insurance processes, we wanted to include some specific information for families who have a child either on GH therapy or will be starting GH injections. This information does not guarantee insurance approval but is meant to provide information that may be helpful when considering your benefit coverage.
External Appeal Process Information
The MAGIC Foundation realizes that families are often left without resources when trying to file appeals, especially so at the external appeal stage. An insurance company must provide you with the opportunity to file an external appeal after all of your internal appeals are exhausted. The external appeal is considered the last appeal available to a member and the determination is final.
In an effort to provide support for our families, MAGIC provides assistance with external appeals via our appeals department or with online external appeal templates.
In order to help you understand the usual external appeal process, we have included some considerations you may want to think about when choosing an insurance company. Even though you, hopefully, will never need to do an external appeal, it is good to do your homework beforehand so you are well prepared if an external appeal becomes necessary.
Here are some points to consider:
Know your Pediatric Office Policy on Appeals:
Some Pediatric Endocrinologists may NOT do appeals for you! Know this before you make an appointment for the first time with them. Without their support, it is very difficult to obtain approval if denied by your payor. If you have no other choice, you will need to gather all of the information needed to write your own appeal(s), this is permissible but cumbersome. Look for help with internal appeals with your GH company’s coordinator for first and second level appeals. Ask your clinician the name of the individual in their office who handles the process of GH coverage; it may be a specific person and you need to find out from them what their process is when submitting for insurance approvals, you also want their timeline for submitting documentation, and what they need from you to help your child receive approval for their GH therapy. Contact them regarding the status of your request for treatment or appeal in process as they may forget to notify you.
Know your Insurance’s GH Benefit Coverage Policy:
You need to understand the criteria/requirements to obtain approval of GH therapy for a specific plan. In many cases if all of the insurance companies GH policy requirements are not met, then denial of therapy will occur. Insurance companies will no longer approve GH treatment with flunked GH Stimulation Tests as definitive of pediatric growth hormone deficiency (PGHD) and your request for therapy must show that your child meets the other GH policy requirements as well.
Pre-Certification or Pre-Authorization Forms:
Be aware that your insurance company will most likely have a pre-certification or pre-authorization form that your pediatric endocrinology clinician will complete when writing the statement of medical necessity (prescription) request for GH for your child. This list may have check-boxes or yes or no answers that correspond to your insurance plan’s criteria and will often cause denials when the information provided does not match the company’s GH policy. When this occurs, you or your doctor will receive a denial letter. Do not assume it is being handled if you have not heard anything from either your insurance plan or your doctor’s office. Check frequently for updates on approval either with the plan, the doctor’s office, or your GH drug’s coordinator. The denial letter will quote the policy’s requirements for meeting medical necessity and it should include the information stating why your child’s diagnosis did not meet these requirements. If the letter does not provide this specific information, you can call them and ask for their reasoning. To increase your chance of approval, the appeal (first and/or second internal appeal) letter should address these specific areas and provide reasons why your child either met the requirements or didn’t need to meet the requirements. Review committees make decisions based on the information they receive. They can also make inaccurate assumptions on the information provided. The appeal letter written by your HCP for your internal appeal, should address these areas if this has occurred.
Continuation of Therapy:
If your child was previously approved for GH therapy with another insurance company, and you now have a new insurance plan, you must go through the same pre-certification process as if your child was just starting therapy for the first time. Continuation of therapy requests are accepted only after your current insurance company has previously approved GH treatment and you have met their original pre-treatment criteria.
Diagnosis Exclusions:
If your child has a diagnosis of Idiopathic Short Stature, they must meet the FDA indication parameters for GH treatment. They must be -2.25 SDS below the mean or 1.2% percentile in height. Plans that exclude ISS can be challenged on their exclusion but only when your child meets the FDA’s indication criteria.
If your child has a diagnosis of Small for Gestational Age, they must meet the current consensus guidelines for GH treatment which is defined as having a birth weight and/or length of −2.0 standard deviations (SDS) for gestational age and the child fails to manifest catch-up growth by two years of age, (defined as height at least two standard deviations below the mean for age and sex. Birth and pediatric records are critical documents that need to include the information showing your child meets the diagnosis specifications.
Turner Syndrome patients, Noonan Syndrome patients, SHOX Syndrome and Prader-Willi patients will all need to show a karyotype (blood test) result confirming the diagnosis. If these conditions are excluded from your plan, appeals can be written using the FDA approved indication for GH therapy for these diagnoses as long as your child matches the FDA indication parameters for GH use.
Appeal Deadline Dates:
Deadlines for submitting an appeal can be 2, 3, 4, 6 or 12 months from the ORIGINAL denial letter or the last denial letter. Every denial letter will inform you of the next appeal available to you (second level or external appeal) and the amount of time you have to submit the appeal. The letters can be confusing, ask your HR benefits manager or the plan itself for clarification if you are unsure of the deadline date or the appeal level. MAGIC requires a minimum of 4 weeks to generate an external appeal due to number of requests received, the amount of research involved in developing the appeal and because of department time limitations. If your application has a date that is less than 4 weeks from your submission deadline, we will have to refuse your application. At times, because of high demand, we may need to temporarily stop accepting appeal requests.
Finally, you are your child’s best advocate. You should not rely solely on your pediatric endocrinologist or their office in handling appeals for your case. Be informed, know your benefit coverage, your contact people, both for your insurance plan and for your doctor’s office; know their office policy on appeals. Be aware of deadlines and stay in communication with pertinent parties.
MAGIC’s appeal department can also answer questions regarding external appeals, even if you do not submit an application for assistance. Our email address is appeals@magicfoundation.org. We hope you find this information helpful in your journey.
The MAGIC Foundation offers assistance with EXTERNAL APPEALS ONLY. Below is information to assist you through the insurance appeals process.
Frequently Asked Questions
Q. I am so confused and just do not understand my prescription drug benefits.
A. Navigating your prescription drug benefits can be confusing! Are you looking to better understand how prescription drug benefits work? If so, click here for a complimentary guide that should answer all your questions.
Q. Do you struggle with being able to afford treatment for Pediatric Growth Hormone Deficiency?
A. Click here to download a discussion guide that will help you start the conversation with your doctor about cost-saving treatment options.
Q. What do I do if my Prior Authorization has been denied?
A. Consult your doctor as soon as possible and they will file the necessary paperwork.
Q. How do I get interim medication?
A. You should be assigned a caseworker from the manufacturer of the chosen medication to aid you and the physician in this process. Make sure the physician is aware you wish to receive medication while beginning the appeal process so that all forms are filled out correctly.
Q. Is there any help with co pay assistance?
A. Click here for a list of programs that may be able to assist
Q. Does my insurance cover growth hormone?
A. In the "Medical Policy" section of your insurance packet it should describe what types of growth hormones are covers and for which diagnoses.
Q. What criteria/testing does the insurance need for approval?
A. You or your Endocrinologist can find this out by speaking with your insurance company.
Q. Where can I go for help with the external appeal?
A. The MAGIC Foundation has a fantastic program to help guide you through the steps in the External Appeal Process. This is usually the final step in the appeal process. This appeal is usually done with the state or outside third party. The doctor usually will not help with this step as it is very time consuming. The MAGIC Foundation is a great resource to aid you in hopefully reversing the denial!
Q. What can I do if my external appeal is denied?
A. You can re-start the process the next year and you can file a complaint with the State Insurance Commissioners (use link to open information on how to file complaints) regarding your denial. Be forewarned, it may not change the denial decision. https://www.thebalance.com/complaints-to-state-insurance-commissioner-2645484. Another good resource regarding the process to file a state complaint, with a link for each state, is: www.CoverageRights.org.
Understanding the Appeal Process
Your doctor’s office will send a prior authorization request to your insurance company for medications before sending the actual prescription to be filled. Your insurance company will either approve or deny the request within a short period of time (typically 24-48 hours). When prior authorization for the patient is denied, the appeals process begins. Depending on your insurance company and the specific rules that have been established for that particular plan, a member may have the opportunity to appeal one, two or three times. The member should review their insurance plan guidelines to find out how many appeals will be allowed.
Become familiar with your state’s laws and Insurance policy & the insurer’s guidelines.
Laws – Some states have laws that define medical necessity and have standards for HMO plans to abide by. These state laws are commonly referred to as statutes and can be accessed on your state’s website.
Deadlines – An appeal is allowed a certain amount of time to be filed. It is critical that an appeal is submitted within the amount of time allowed by the insurance company. The denial letter includes the number of days that an appeal must be filed by.
Exclusions – Review your actual policy in order to confirm that the treatment you are seeking approval for is or is not covered.
Self-funded plan vs. fully insured plan – Check with your human resources office to find out which plan you have. Those with fully insured plans have the option of an external appeal, which is independent of the insurance company, typically submitted directly to the state. Those with self-insured plans have the right to an external appeal however it is submitted directly to the insurance company, which then gets forwarded to a third party reviewer. The employer has the ability to override the adverse decision.
Sample Appeal Letters
Sample templates are free but if you would like the Appeals Coordinator to work with you on your letter or have extensive questions, a $75 fee will be necessary in order to cover this service
Patient Assistance Programs
There are a number of patient assistance programs and co-pay assistance options available. Please check them out to see if you qualify for any assistance.
Follow up procedure
If all internal appeals have been denied and you wish to request assistance from The MAGIC Foundation for your external appeal, please click here for more information.
"The MAGIC Foundation has been a HUGE blessing to our family. During a time when we continually were experiencing lack of support or avenues to venture down, we came across MAGIC. After hearing so many, I'm sorry I can't help you... or your daughter doesn't qualify... It was refreshing to hear a friendly, warm, reassuring voice on the phone who was optimistic and open to help. It almost felt unreal, but it wasn't! Without the support of the MAGIC Foundation, our precious little daughter wouldn't have been approved for growth hormone therapy. The Insurance Appeals Specialist from MAGIC really went to bat for our family and was by our side the entire way through. She was even present on the telephonic hearing call which was held with a judge and several opposing individuals from insurance companies, which literally meant the world to me! We can not fully express the gratitude and appreciation for what the MAGIC Foundation provides to families like ours. Thank you, for all that you have done and continue to do! It really matters and makes a world of difference to our little children. God bless you all!"
- B. Ma, California
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