How to appeal a denied scleral lens claim

You have the right to appeal

If your health insurer refuses to pay a claim, it has to tell you why and how you can dispute the decision. HealthCare.gov describes two levels:^[1]

• Internal appeal: you ask the insurance company to conduct a full and fair review of its own decision.
• External review: an independent third party reviews the decision, so the insurer no longer gets the final say.

This page follows the federal process HealthCare.gov describes for health insurers. Vision plans, Medicare, Medicaid, and some employer plans have their own processes. Your denial letter should tell you which applies.

Step 1: Find out exactly why

The reason shapes everything that follows. Common reasons for scleral lens denials include:

• Not medically necessary under the plan’s criteria. For example, the records didn’t show a required test result. One vision plan’s criteria for keratoconus call for topography, OCT, corneal mapping, or keratometry.^[5]
• Excluded benefit. Some medical plans exclude contact lenses except for narrow uses. Aetna’s policy, for instance, covers scleral lenses used as a bandage for severe ocular surface disease even under plans that exclude contact lenses, but not lenses for keratoconus.^[6] A denial might mean the claim belongs under a different plan, or that the diagnosis on the claim didn’t reflect why the lens was prescribed.
• No prior authorization when one was required.
• Wrong benefit or code. A claim processed under an elective contact lens benefit instead of a medically necessary one.
• Out of network with no out-of-network benefit.

If the letter isn’t clear, call the plan and ask what specific information would change the decision.

Step 2: File an internal appeal

For most private health plans, you must file your internal appeal within 180 days (6 months) of receiving the denial notice.^[2] To file, you complete the insurer’s forms, or write to the insurer with your name, claim number, and insurance ID number. You can submit any additional information you want considered, such as a letter from your doctor.^[2]

For a scleral lens appeal, that usually means:

1. Your fitter’s letter of medical necessity, updated to answer the specific reason for the denial, point by point against the plan’s criteria.
2. Supporting records: topography or other test results, vision measurements with glasses and with lenses, and notes on other lenses and treatments already tried.
3. The plan’s own policy, if a written criterion supports your case.
4. Your own short letter, if you want, explaining how the condition affects your daily life.

The Consumer Assistance Program in your state can file an appeal for you.^[2]

If your situation is urgent, the insurer must speed up the process, and you can ask for an external review at the same time.^[1][2]

Step 3: Ask for an external review

If the internal appeal is denied, you can usually request an external review. You must file a written request within 4 months of receiving the final denial.^[3] External review covers denials involving medical judgment where you or your provider disagree with the plan, among others. The reviewer either upholds the insurer’s decision or decides in your favor, and the insurer is required by law to accept the decision.^[3]

Standard external reviews are decided no later than 45 days after the request is received; expedited reviews, no later than 72 hours.^[3] Your explanation of benefits or final denial letter gives the contact for the organization that handles your external review.^[3]

If you have Original Medicare

Medicare has its own appeals process. One point matters before care starts: if a provider gives you an Advance Beneficiary Notice of Non-coverage, the option you choose affects your appeal rights. If you choose to receive the item and have a claim submitted, you can appeal if Medicare denies it. If you ask that no claim be sent to Medicare, you can’t appeal.^[4]

What to ask

Your plan:

1. What is the specific reason for the denial, and which policy or criterion was applied?
2. What information would change the decision?
3. What’s my deadline for an internal appeal, and where do I send it?
4. Can my doctor file for me? Is there a form?
5. Is there a peer-to-peer option for my doctor to discuss the case with the plan’s reviewer?

Your fitter:

1. Can you update the letter to address the denial reason?
2. Which test results support each criterion?
3. Will you file the appeal, or should I? Is there a fee?

Rules and deadlines vary by plan type and change over time. Your denial letter and plan documents are the final word on the process that applies to you.