Perhaps you have joint problems related to your rotator cuff, hips, back, knees, or other types of musculoskeletal issues. According to the World Health Organization, about 1.71 billion people across the globe suffer from musculoskeletal conditions. These conditions are the leading contributor to disability as well, significantly limiting mobility and dexterity, and reducing the ability to participate in society. In fact, in 2021, at 27.7%, spending on musculoskeletal outpatient procedures was higher than that for any other type of outpatient procedure. Musculoskeletal impairments comprise more than 150 different diseases and conditions, characterized by pain and impairment in muscles, bones, joints, and connective tissues. Some of the most common musculoskeletal impairments include:
- Rheumatoid arthritis
- Psoriatic arthritis
- Carpal tunnel syndrome
Musculoskeletal conditions often co-exist with other diseases like cardiovascular disease and can increase the risk of developing other diseases. Because musculoskeletal conditions can cause chronic pain and limited mobility, those with these conditions are also at a higher risk of developing mental health issues. Although the prevalence of musculoskeletal conditions increases with age, younger people can also be affected. Childhood auto-immune inflammatory conditions like juvenile arthritis can even affect a child’s development.
If you suffer from a musculoskeletal condition that causes chronic pain and limited mobility and your physician prescribes a promising new treatment, it can be extremely disheartening to find out that your insurance company has denied the treatment. Your musculoskeletal treatment denied by insurance can feel as though you are all alone and that nobody cares about your pain or your future. Fortunately, this is simply not true.
You have a strong ally in attorney Scott Glovsky. Scott has a deep understanding of just how many ways an insurance denial for a treatment that could help you can affect your life. He truly understands your pain and will work hard on your behalf, never hesitating to go up against a big insurance company that is failing to live up to its end of the bargain. Early in his career, Scott worked on the other side—for insurance companies. Because of this, he knows the tricks in their books, as well as how to combat these tricks.
What Are the Most Common Reasons for an Insurance Denial?
You likely received an Explanation of Benefits that detailed a musculoskeletal treatment denied by insurance. Read the explanation of the denial. These denials generally fall into two distinct categories—technicalities, which include missing codes or other claim filing mistakes, or medical, meaning the treatment is not considered a medical necessity or is believed to be investigational or experimental. If the claim has missing or incorrect information, was not filed within the allowed time frame, you are not eligible for the benefit requested, the service was not preauthorized, your provider is out-of-network, or the medication is not on your plan’s formulary, the “fix” may be relatively simple. If the medication your doctor prescribed is not on your plan’s formulary, is on a specialty tier, requires step therapy, or is deemed investigational, your doctor can help you appeal in one of the following ways:
- Request that step therapy be waived by proving you have “failed” on lower-tier drugs
- Request an exception due to medical necessity
- Provide proof from peer-reviewed medical journals that the medication is necessary
If the services are deemed not appropriate, this means your insurer is stating that the treatment is not medically necessary, not considered appropriate in a specific healthcare setting, or the effectiveness of the medical treatment has not been proven. Your provider can potentially get an experimental or investigational treatment approved by explaining to the insurer that the treatment is medically necessary, you’ve tried and failed other treatments, or the treatment was covered for other patients with similar medical conditions.
What Steps Should You Take Following a Musculoskeletal Treatment Denied by Insurance
It can be easy to panic following a musculoskeletal treatment denied by insurance. If your doctor believes you will significantly benefit from the treatment, but you are financially unable to pay for the treatment on your own, you can end up feeling frustrated, angry, and scared. You should have received a denial explanation. If the denial is due to an error that can be corrected, take the steps to do so. If the denial is based on a lack of medical necessity, or that the drug or treatment is experimental or investigational, you could benefit significantly from having a strong advocate by your side, like Scott Glovsky.
Scott can help you file an internal appeal with your insurance company, ensuring you properly meet all filing deadlines. You will likely need to resubmit your claim along with a letter from your doctor describing why the treatment is necessary. If your issue is urgent, you can file an expedited appeal and you will have a response within 72 hours. Otherwise, for claims for treatment not yet received, your insurer has 30 days to respond, or 60 days for a claim for treatment already received. If your internal appeal is denied, you can file an external appeal. An independent review organization will review your claim, making a final decision as to whether your insurer must pay for your musculoskeletal treatment.
Which Companies Are Most Likely to Deny Insurance Claims
Any health insurance company can potentially deny an insurance claim, although some companies deny claims more often than others. In 2022, Experian Health distributed the following statistics. Three-quarters of health professionals surveyed stated that healthcare claims are denied at least 10-15 percent of the time, and few people appeal these decisions. Californians may have claims denied by Anthem Blue Cross, Blue Shield, Health Net, Cigna, Kaiser, UnitedHealthcare, Aetna, and others.
What Drugs Are Commonly Used for Musculoskeletal Health Conditions?
Some of the newer drugs and treatments for musculoskeletal health conditions include the following:
- Biologic DMARDS are proteins that target specific proteins in the body that fuel the symptoms of inflammatory arthritis. These drugs are either injected or taken orally.
- Interleukin-6 inhibitors include tocilizumab and sarilumab.
- TNG (tumor necrosis factor) inhibitors calm inflammation and may include adalimumab, infliximab, etanercept, golimumab, and certolizumab pegol.
- Methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide are older inflammatory arthritis drugs that—with the exception of methotrexate, which is given via injection—are all taken orally.
- Rituximab is a drug that works by depleting white blood cells that play a role in the immune response and are involved in the formation of autoantibodies.
- JAK inhibitors are newer drugs to inhibit the proteins involved in inflammation and can include baricitinib, tofacitinib, and upadacitinib.
- IL-1 inhibitors block IL-1, another immune system protein involved in inflammation, and includeanakinra and canakinumab.
- Abatacept interferes with immune T-cells that can cause inflammation and rheumatoid arthritis.
How Can Attorney Scott Glovsky Help You Following a Musculoskeletal Treatment Denied by Insurance?
Following a musculoskeletal treatment denied by insurance it is imperative that you speak to attorney Scott Glovsky who can help you through the process of appeals, getting you the treatment you need. At the Law Offices of Scott Glovsky, Scott and his legal team are uniquely equipped to appreciate that there is a real human being with real health issues behind every case. We understand that insurance companies are often impersonal and uncaring, prioritizing their profits over people and their lives. We prepare every case comprehensively, ensuring each case is ready for trial. Contact the Law Offices of Scott Glovsky today to get the help you need from experienced, compassionate legal professionals.