Recap

This is part 7 (the final part!) of a multi-part post walking through an appeal of a coverage denial for Adalimumab level testing. We previously submitted an external appeal of the initial decision to a third party review agency.

The Response

On September 9th, I received a thin envelope regarding the external appeal. Upon seeing the size of the envelope I had resigned myself to losing the appeal and moving on with my life, however I was pleased to find that this letter was merely acknowledging receipt of my external appeal. The letter was from a company called MCMC, which, it turns out, is a company that does extensive work serving as an external review party for numerous states. The letter essentially stated an address where additional supplementary appeal materials could be sent, and specified a timeline (30 days, in my case) for finalizing a decision for the case.

On October 5th, I received another letter from the same address, but this time it was a thick one with numerous contents. I was, and still am, amazed to find that this letter dictated that my plan's denial of coverage for Adalimumab level testing was being OVERTURNED.

It turns out that humans other than myself (three humans!) unanimously agreed that the decision by my insurer to deny this coverage was faulty according to the plan documents, and that my health plan must cover the original services. And thus was the decree of the review board.

The exact wording of the final decision was:

Majority panel determination: Approval (Health plan denial of coverage Overturned, health plan must cover the requested health service.)

Absurdity

You may have noticed that while I posted pictures of letters I sent and received throughout this appeal process in all of my prior posts, the post where I claim to have won the appeal suspiciously has no picture proof. The reason for this is that both letters I received from MCMC were marked "Confidential" at the top. I have no idea what, if any, legal weight such a dictation might hold if the recipient were to share the contents, but I decided to not pre-emptively annoy the one organization from this long journey who actually seemed to be on my side. Aside from wanting to redact personal information of the review board (which was already anonymized), I don't know why such an organization would care to ensure everything is confidential, as IMO this entire hell-scape of a process is in dire need of more transparency and accountability. In any case, I plan to reach out to MCMC to see if they'd bless my use of a redacted copy of their letters in this post. In the meantime, I suppose you'll just have to take my word for the result of the external appeal.

Parting Words

If you've made it this far, I truly hope reading this has been of some use to you in dealing with your own health insurance. In every appeal I've ever submitted, the process has been a pain, and required effort that brings into question the value proposition of even trying to appeal. But I am fortunate to say I've never had a coverage decision on which my life depended, and I know that is not something that can be said of all those who are fighting insurance decisions.

If you are in a bad place and dealing with something like this, I'd love to hear your story, and to try to help in any way I can. You can reach out to me personally at mike@persius.org, or submit a request for help with your insurance denial by signing up for a completely free account at persius.org.

Thanks for reading!