Your doctor needs your help if your health insurance denies coverage for your migraine medication, device, or procedure.
Do not just settle for an alternative medication (we will assume medication for simplicity, but you can substitute device or procedure with only a few minor changes) that you weren’t initially prescribed because health insurance denied the medication that works best for you. You can advocate for yourself.
It's possible your health insurance company will approve coverage after a second review. However, being proactive is necessary to overturn any decision. Try the following.
The first thing you need to do is call your health insurance provider. Here is a sample script (adjust when appropriate):
You: Hello, my name is [your name] and I'm calling about claim number [claim number] that was denied.
A**hole company: Yes, what can I help you with?
You: I received a letter saying my claim for [medication name] was denied. However, my neurologist, Dr. [doctor's name], believes this medication is absolutely necessary for me to treat my migraines disorder so I don’t end up disabled/more disabled.
As per the health insurance requirements, the medication was prescribed after we tried several other preventive medications that either didn't work or had intolerable side effects. [Medication name] is the only medication that has been effective at reducing the frequency, duration, and severity of my migraine attacks.
Without this medication, I will continue having disabling migraine attacks that will leave me unable to work or care for my family. My migraine attacks are extremely painful and debilitating. This medication has given me my quality of life back (if you never were authorized the medication, mention the samples your neurologist gave you).
My doctor has also provided a letter of medical necessity (Make sure they do this) further detailing why this medication is needed. Could you please review this claim again and take the doctor's letter into consideration?
I'm also happy to provide any other information needed upon request.
A**hole company: I understand. Let me take another look at the claim and the documentation from your doctor.
You: Thank you, I really appreciate you taking the time to re-review this claim. This medication has made such a difference for me, I want to do everything I can to get coverage for it. Please let me know if any other information would be helpful.
A**hole company: Okay, we'll be in touch once I've had a chance to fully reassess the claim.
You: Great, I look forward to hearing back. When do you think that will be?
A**hole company: 2-3 weeks.
You: Great, I’ll check back in then. Thank you again for your help.
You want to show the health insurance company that it is not the first, second, or third medication you tried for this specific purpose (either as a preventive or abortive) because health insurance companies will want to see you have tried other medications that are first-line for the condition.
It is possible that the first representative may be difficult with you. Ask for their supervisor. Don’t give up until someone agrees to reevaluate your claim. Persistence is key.
Provide a Letter
As mentioned in the script, you need to make sure your doctor provides a detailed letter outlining your diagnosis, past treatments tried and responses, and why this medication is the only appropriate treatment option left. If not, tell him to write it out. You may also write it out for your doctor to make things go faster (unfortunate, but sometimes necessary). They will double check if everything you wrote is accurate then sign it and send it out. Make sure you ask for a signed copy as well in case insurance asks you for this letter too.
Do not throw anything out. Record phone conversations (if the laws in your state allow). Keep a record of everything and get all denials in writing. Be polite.
Your Employer Can Help
Ask your employer's HR department to get involved and apply pressure to the insurance company.
Send a certified letter to the upper management of the health insurance company as well as their e-mails, which can be found online. Do not continue sending e-mails or letters. One and done. In the letter and e-mail, include all the documentation and everything that you have been through to try and get approval. Remember, they don’t know you or your story. You will have to retell it. Include your claim number and other pertinent identifiers.
In the meantime:
- See if the medication manufacturer has a patient assistance program to help with costs if insurance continues to deny.
- Check your state laws. Find out if your state has laws requiring insurance to cover certain medications, if prescribed. Your doctor can advocate based on these laws. It is unlikely in the case of migraine medication, but it is worth a try.
- File a consumer complaint with your state's insurance regulatory agency regarding the denial.