Doctor support is critical to patients getting the health benefits they deserve. In health claims, we often see patients who are seeking medication or treatment that is deemed “experimental” or “investigational” by an insurance company, even though other insurance companies may approve the same medication or treatment. The claims that succeed are those that have stellar doctor support. Doctors want to help but need direction. Here are some pointers for patients to get doctor support for health claims.
First, get it in writing. The doctor may have mentioned to you that studies have shown that the recommended treatment is appropriate for your condition. That’s not enough, you need it in writing. Make an appointment with the doctor or his office manager. Explain that you are asking the insurance company to pay for treatment that the doctor has prescribed for you and that you need a letter of support. Most doctors are happy to provide a letter explaining their treatment recommendations.
Second, address the insurance company’s specific concerns. If the insurance company is claiming that the treatment or medication is FDA approved for other conditions, but not your condition, give facts and argument that explain why it is appropriate for your condition. Provide studies (by reference or attach copies) that support your argument. Obtain letters from other patients with the same condition who received benefits for the same treatment.
Third, write your own letter to the insurance company explaining why the treatment is medically necessary. Write about your experience with the requested treatment, or, your inability to get effective results with alternative treatment. If the matter is eventually litigated in court, the letter will be important evidence for the judge or jury to consider the patient’s experience.