Knowing When You Can and Cannot Appeal

What You Need to Know

Substantive denials occur when an insurance company refuses to pay for a service or device on the ground that it is either (a) not medically necessary or (b) experimental/investigational. 

1. Medical Necessity: Health plans often have specific criteria to determine if a treatment is medically necessary. For example, health plans frequently have specific medical necessity requirements for microprocessor-controlled knees and myoelectric arms/hands. Similarly, they require specific findings in the medical record to support the delivery of custom-fit or custom-fabricated braces.  
2. Experimental/Investigational: Health plans are more likely to designate newer/costlier prosthetic and bracing solutions as experimental.

In either case, substantive denials come with a right to appeal. Patients and providers have the opportunity to contest the insurer's decision by providing either additional documentation establishing medical necessity or evidence showing that the prescribed treatment is not experimental.

Technical denials, on the other hand, occur when a claim is rejected due to policy exclusions - i.e., "This policy does not cover powered prosthetic or orthotic devices." - or non-compliance with health plan insurance requirements (e.g., the patient was no longer on the health plan in question at the time of care). 

Unlike substantive denials, technical denials typically do not come with appeal rights, as they are based on the terms of the insurance contract itself.

What this Means for You

Understanding the distinction between substantive and technical denials is essential. While substantive denials offer a pathway for appeal, technical denials are definitive, as the premiums paid by the insured individual for that health plan reflect the non-coverage of those items. Effective advocacy means not only fighting for your patients when a claim has been wrongly denied on substantive grounds, but knowing when youcannotappeal as well.