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Law Offices of Scott Glovsky

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OUR OFFICES:
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    • Call: (909) 296-7700
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    • Call: (626) 243-5598

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          • Humira
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          • Ketamine
          • Leqembi™
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          • Mounjaro
          • Orthovisc
          • Ozempic
          • POLIVY
          • Radicava
          • Remicade
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          • SpaceOAR Hydrogel
          • Stelara
          • Wegovy
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          • Zolgensma
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          • Postural Orthostatic Tachycardia Syndrome
          • Residential Treatment Center (RTC)
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  • Home
  • About
    • About Our Firm
    • Attorneys
    • How Our Firm Has Changed Lives
    • How We Operate
  • Practice Areas
        • Health Insurance Denials
          • Insurance Bad Faith
          • Health Insurance Claim Denials
          • Medical Necessity Denials
          • Experimental/Investigational Denials
          • Out-of-Network Denials
          • Insurance Policy Rescission
          • Health Insurance Denials Public Employees
          • Medicare Advantage Health Insurance Denial
          • We Fight All Health Insurance Companies, Including:
            • Aetna Denial
            • Anthem Blue Cross Denial
            • Blue Shield of California Denial
            • Cigna Denial
            • Health Net Denial
            • Kaiser Permanente Denial
            • OSCAR Health Plan Denial
            • Magellan Healthcare Denial
            • Molina Healthcare Denial
            • Regal Medical Group Denial
            • UnitedHealthcare Denial
        • Medications
          • Prescription Denial
          • Gene Therapy
          • Cancer Treatment
            • Proton Radiation Therapy
          • New Cancer Drugs
          • Expensive Drugs
          • Biologic Drugs
          • Cosentyx
          • Dupixent
          • Enbrel
          • Entyvio
          • Euflexxa
          • Harvoni
          • Humira
          • Intravenous Immunoglobulin (IVIG)
          • Ketamine
          • Leqembi™
          • Monovisc
          • Mounjaro
          • Orthovisc
          • Ozempic
          • POLIVY
          • Radicava
          • Remicade
          • Synvisc
          • Spinraza
          • SpaceOAR Hydrogel
          • Stelara
          • Wegovy
          • Xeljanz
          • Xifaxan
          • Zolgensma
        • Injuries & Surgeries
          • Spinal Cord Injury
          • Brain Injury
          • Surgery
          • Back Surgery
          • Ablation Surgery
          • Prosthetic Limb
          • Respite Care
          • Pain Treatment
          • Partial Hospitalization
          • Magnetic Resonance Imaging (MRI)
          • Radiofrequency Ablation (RFA)
        • Health Conditions
          • ALS
          • Alzheimer’s Disease and Dementia
          • Autism
          • Autoimmune Disorders
            • Ankylosing Spondylitis
            • Crohn's Disease
            • Fibromyalgia
            • Multiple Sclerosis
            • Lupus
          • Blood Disorder
          • Cancer
          • Cerebral Palsy
          • COVID-19
          • Counseling
          • Diabetes
          • Eating Disorder
          • Genetic Testing
          • Genomic Testing
          • Heart Condition
          • Hydrocephalus
          • Intensive Outpatient Program
          • Mental Health
          • Migraine
          • Obesity
          • Osteoarthritis
          • Parkinson's Disease
          • Postural Orthostatic Tachycardia Syndrome
          • Residential Treatment Center (RTC)
          • Rheumatoid Arthritis
          • Skin Treatment
          • Spinal Muscular Atrophy
          • Substance Use Disorders & Addiction
          • Ulcerative Colitis
        • Personal Injury
          • Accidents
            • Bicycle Accidents
            • Car Accidents
            • Motorcycle Accidents
            • Truck Accidents
          • Traumatic Brain Injury
          • Catastrophic Injury
          • Burn Injury
          • Wrongful Death
          • Premise Liability
          • Slip & Fall
          • Product Liability
          • Nursing Home Abuse
          • Elder Abuse
        • Sexual Abuse
          • Types of Sexual Abuse
          • Child Sexual Abuse
          • Campus Abuse
          • Special Needs Abuse
          • Abuse at School
          • Abuse at Camp
          • Abuse by a Clergy Member
          • Abuse by Athletic Coaches
        • Business Issues
          • Employment & Business Issues
          • Broker & Agent Negligence
          • Business Contingency Litigation
          • Unfair Business Practices
          • Workplace Harassment
          • Wrongful Termination
          • Whistleblower
            • Qui-Tam
  • Results
    • Testimonials
    • Case Results
  • In The Media
  • Resources
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    • Trial Lawyer Talk Podcast
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  • Contact

Los Angeles Medical Necessity Denial Appeals Process for Non-ERISA Policies

Home » Los Angeles Bad Faith Insurance Lawyer » Los Angeles Health Insurance Denial Lawyer » Los Angeles Medical Necessity Denials Lawyer » Los Angeles Medical Necessity Denial Appeals Lawyer » Los Angeles Medical Necessity Denial Appeals Process for Non-ERISA Policies

A plan is not governed by ERISA if it is an individual or family plan, one bought directly from an insurance company for an individual or bought through a state insurance marketplace exchange, or a group employment health plan purchased for a state or municipal employee or employee of a religious organization. If your plan is in fact governed by ERISA, you can learn more about the medical necessity denial appeal process here.

If your physician ordered a specific test or treatment for your medical condition and you received a denial letter from your insurance company, you are probably wondering what options you have. An experienced attorney can help you understand and navigate the Los Angeles medical necessity denial appeal process for non-ERISA policies so that you can get the coverage you need.

Page Contents:

  • What is a Medical Necessity Denial?
  • A Policyholder’s Right to Appeal
  • Non-ERISA Appeals Process
  • Secondary Appeals and External Reviews
  • Value of a Los Angeles Medical Necessity Denial Appeals Attorney

What is a Medical Necessity Denial?

At its core, a denial is simply a contract dispute. Someone believed their insurance would cover a certain test or treatment but the carrier denied they had a contractual obligation to do so. This makes the appeals process two-pronged. First, it should be based on the reason they are denying the coverage. Second, it should also cover the provisions in the insurance policy.

A Policyholder’s Right to Appeal

For non-ERISA policies, policyholders have the right to appeal their health insurance plan decisions under the Affordable Care Act (ACA) and California law. However, they must follow the process set by the insurance carrier for appeals. In some plans, this can involve multiple appeals.

The Los Angeles medical necessity denial appeals process for non-ERISA policies can be time-consuming and cumbersome. Therefore, many who are denied health insurance coverage turn to the services of an experienced health insurance lawyer to help them win their appeals.

Non-ERISA Appeals Process

The Los Angeles medical necessity denial appeals process for non-ERISA policies begins with the patient receiving a denial letter. In this letter, the insurance carrier must tell them:

  • Their reasons for denial
  • That the person has a right to an appeal and how to submit one
  • The deadline to appeal
  • About any Consumer Assistance Programs in the state that help with medical necessity claim denial appeals

Then, the patient or their attorney can request the support of the physician who ordered the test or treatment. A written letter stating the medical reasons the claim should be approved is usually best. They should provide the insurance carrier with treatment notes and medical records, including any test results. It is also recommended that the patient submits current medical literature or peer-reviewed articles that uphold the effectiveness of any claims involving investigational or experimental services.

Finally, a personal narrative can be quite effective in an appeal. The narrative should describe the need for the requested service. It can be written by the patient, their attorney, or another authorized representative. All this information should be mailed certified with delivery receipt to ensure the carrier receives it on time.

Secondary Appeals and External Reviews

If the insurance company still denies the claim, the policyholder has the right to a second appeal. This means their file will be reviewed by a medical director from their insurance company. Other levels of appeals may be necessary if the treatment the patient’s doctor recommends is considered investigational or experimental.

Under Federal Code § 2560.503-1, a person cannot be forced to submit more than two appeals prior to filing a lawsuit against a health insurance carrier. In addition, a carrier cannot charge someone to file an appeal.

Furthermore, the policyholder has the right to an independent external review for a claim. These reviews use the opinions of a board-certified physician in the same specialty as the patient’s physician and an independent third-party reviewer.

Value of a Los Angeles Medical Necessity Denial Appeals Attorney

Your final option is to file a claim in court. Having an experienced attorney can help increase the chances that your appeal will be granted. They can advocate on your behalf to get the coverage you need. A knowledgeable attorney knows how to make the Los Angeles Medical necessity denial appeals process for non-ERISA policies easier and less time-consuming on policyholders. Contact us today for a free consultation.

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The Law Offices of Scott Glovsky is a Professional Corporation. Information on this website is not intended as and is not legal advice. The information does not establish an attorney-client relationship. Case results are not a prediction or guarantee of potential case outcomes. This website is an attorney advertisement.

  • Home
  • About
    ▼
    • About Our Firm
    • Attorneys
    • How Our Firm Has Changed Lives
    • How We Operate
  • Practice Areas
    ▼
    • Health Insurance Denials
      ▼
      • Insurance Bad Faith
      • Health Insurance Claim Denials
      • Medical Necessity Denials
      • Experimental/Investigational Denials
      • Out-of-Network Denials
      • Insurance Policy Rescission
      • Health Insurance Denials Public Employees
      • Medicare Advantage Health Insurance Denial
      • We Fight All Health Insurance Companies, Including:
        ▼
        • Aetna Denial
        • Anthem Blue Cross Denial
        • Blue Shield of California Denial
        • Cigna Denial
        • Health Net Denial
        • Kaiser Permanente Denial
        • OSCAR Health Plan Denial
        • Magellan Healthcare Denial
        • Molina Healthcare Denial
        • Regal Medical Group Denial
        • UnitedHealthcare Denial
    • Medications
      ▼
      • Prescription Denial
      • Gene Therapy
      • Cancer Treatment
        ▼
        • Proton Radiation Therapy
      • New Cancer Drugs
      • Expensive Drugs
      • Biologic Drugs
      • Cosentyx
      • Dupixent
      • Enbrel
      • Entyvio
      • Euflexxa
      • Harvoni
      • Humira
      • Intravenous Immunoglobulin (IVIG)
      • Ketamine
      • Leqembi™
      • Monovisc
      • Mounjaro
      • Orthovisc
      • Ozempic
      • POLIVY
      • Radicava
      • Remicade
      • Synvisc
      • Spinraza
      • SpaceOAR Hydrogel
      • Stelara
      • Wegovy
      • Xeljanz
      • Xifaxan
      • Zolgensma
    • Injuries & Surgeries
      ▼
      • Spinal Cord Injury
      • Brain Injury
      • Surgery
      • Back Surgery
      • Ablation Surgery
      • Prosthetic Limb
      • Respite Care
      • Pain Treatment
      • Partial Hospitalization
      • Magnetic Resonance Imaging (MRI)
      • Radiofrequency Ablation (RFA)
    • Health Conditions
      ▼
      • ALS
      • Alzheimer’s Disease and Dementia
      • Autism
      • Autoimmune Disorders
        ▼
        • Ankylosing Spondylitis
        • Crohn’s Disease
        • Fibromyalgia
        • Multiple Sclerosis
        • Lupus
      • Blood Disorder
      • Cancer
      • Cerebral Palsy
      • COVID-19
      • Counseling
      • Diabetes
      • Eating Disorder
      • Genetic Testing
      • Genomic Testing
      • Heart Condition
      • Hydrocephalus
      • Intensive Outpatient Program
      • Mental Health
      • Migraine
      • Obesity
      • Osteoarthritis
      • Parkinson’s Disease
      • Postural Orthostatic Tachycardia Syndrome
      • Residential Treatment Center (RTC)
      • Rheumatoid Arthritis
      • Skin Treatment
      • Spinal Muscular Atrophy
      • Substance Use Disorders & Addiction
      • Ulcerative Colitis
    • Personal Injury
      ▼
      • Accidents
        ▼
        • Bicycle Accidents
        • Car Accidents
        • Motorcycle Accidents
        • Truck Accidents
      • Traumatic Brain Injury
      • Catastrophic Injury
      • Burn Injury
      • Wrongful Death
      • Premise Liability
      • Slip & Fall
      • Product Liability
      • Nursing Home Abuse
      • Elder Abuse
    • Sexual Abuse
      ▼
      • Types of Sexual Abuse
      • Child Sexual Abuse
      • Campus Abuse
      • Special Needs Abuse
      • Abuse at School
      • Abuse at Camp
      • Abuse by a Clergy Member
      • Abuse by Athletic Coaches
    • Business Issues
      ▼
      • Employment & Business Issues
      • Broker & Agent Negligence
      • Business Contingency Litigation
      • Unfair Business Practices
      • Workplace Harassment
      • Wrongful Termination
      • Whistleblower
        ▼
        • Qui-Tam
  • Results
    ▼
    • Testimonials
    • Case Results
  • In The Media
  • Resources
    ▼
    • Frequently Asked Questions
    • Trial Lawyer Talk Podcast
    • Fight Health Insurance Denials Book
    • Download Our eBook
    • Helpful Resources
    • Blog
    • Guides
    • Sign Up for Our Mailing List
    • Power of Resilience Scholarship
  • Contact