Not a covered benefit

What it means

The plan says the service is not something your policy pays for. It may point to an exclusion (a list of things the plan never covers), to a limit you have used up, such as a number of visits, or to a service that only some plans include.

A “not covered” label is sometimes right and sometimes the wrong box. The plan may have put a medical-necessity dispute under an exclusion, or the claim may be coded as a service the plan does exclude. Find out which.

Who has to act first

You, with a close read. The denial notice must name the specific plan provisions the plan relied on. Find those words in your plan document (the summary plan description, certificate of coverage or policy). If the notice does not name them, ask for them in writing.

If your plan is a private employer plan, you can ask the plan administrator in writing for the plan documents. A court may order an administrator who does not send required documents within 30 days to pay up to $110 a day, but that penalty is discretionary and only a court can award it.

Appeal within at least 180 days after you receive the notice for a job-based plan or a non-grandfathered individual plan (check the date on your notice, which controls). Medicare, Medicaid and other public coverage differ.

Arguments that work

• The service falls outside the exclusion. Read the exclusion word for word. Plans sometimes apply a broad label, such as “cosmetic”, to care that treats a medical problem. Your doctor’s letter can show that.
• The claim was coded wrongly. If the service was coded as something excluded, ask your provider to check the codes. A preventive visit coded as diagnostic care is one example that consumer and patient sites give. Non-grandfathered plans must cover recommended preventive services without cost sharing.
• A law requires the coverage. Plans that cover mastectomy must cover reconstruction, surgery on the other breast for symmetry, prostheses and treatment of complications, including lymphedema. Non-grandfathered plans may not deny or limit routine patient costs in an approved clinical trial.
• A limit that depends on medical need. If the plan limits visits or days, ask whether more are covered when medically necessary. The federal external review rule gives a visit limit that works this way as an example of a reviewable denial.
• The limit was not counted correctly. Check the plan’s count of visits or days against your own records. Also ask whether the plan’s negotiated discount still applies after a limit is reached; the Arthritis Foundation says it should.
• Mental health or substance use care. A plan may not apply separate limits only to those benefits. See the mental health parity guide for the exceptions.

Evidence to gather

• The denial notice and Explanation of Benefits (EOB) (you).
• The plan document pages with the exclusion (the plan or your employer’s benefits office).
• Your provider’s description of the service and the billing codes used (your provider).
• A letter from your doctor if medical need is part of the argument (your doctor).
• The plan’s visit or day count, and your own records (the plan, you).

What to send

Send an appeal letter that quotes the exclusion the plan cited, says why your service falls outside it or why a law overrides it, and attaches the evidence. Ask for the decision in writing.

When this is not worth an appeal

If your plan document excludes the service by name, the claim was coded correctly, and no law requires the coverage (for a patient under 21 on Medicaid, ask about Early and Periodic Screening, Diagnostic and Treatment, which can require medically necessary services the plan excludes), an appeal can only ask the plan to apply its terms, and it cannot add a benefit the plan does not have. In a self-funded employer plan, the employer may be able to approve an exception, so look at a request to your employer, a lower-cost alternative, a self-pay price, hospital financial assistance, and your options at the next open enrollment.