What to do when insurance says a procedure is not medically necessary?

When you pay for health insurance, you expect it to cover procedures your doctor recommends.  But in many cases it doesn't. For example, consider this story posted on Reddit:

Just found out this morning that my insurance denied the authorization for oophorectomy surgery because it is not medically necessary. My doctor recommended the surgery because of multiple ruptured cysts and possible adhesions. I have an appointment with him to go over other options but I’ve tried pain control and birth control and they don’t help!  I’m furious that a company can override what my doctor deems medically necessary! Is there anything I can do to get my insurance to approve my surgery?

First, let's review the terminology.  The industry term "medically necessary" means a "health service or treatment that is mandatory to protect and enhance the health status of a patient, and could adversely affect the patient’s condition if omitted, in accordance with accepted standards of medical practice."  In short, a medically necessary procedure is required because the patient's condition could deteriorate without it, and customary/typical for the situation.  While this definition seems fairly clear, it still leaves plenty of room for interpretation by insurance companies.

In the story above, the insurance company might focus on the word "recommended".  To recommend is not to insist.  It doesn't imply medical necessity.  If the doctor only recommended something, it sounds medically optional.  And if something is medically optional, an insurance company is not generally obligated to cover it.

The starting point for any dispute with an insurance company is be your insurance agreement.  It should clearly define what your coverage is.  Ideally, you should equip yourself with that knowledge before even requesting pre-approval for a procedure.  Quote from the insurance agreement liberally, because it helps both sides stay focused on black-and-white obligations.

If you find your insurance agreement seems to authorize a procedure, but your insurance company refuses to cover it, you have a few options:

• Appeal the insurance company's decision.  Ask the insurance company to escalate and re-review your request.  Basically, your hope is that someone else will view your request differently than the person who rejected it.  Your efforts will be much more effective if you have documentation indicating the procedure is covered under your insurance agreement, and/or should be considered medically necessary.  For example, you might ask your doctor for a letter stating they consider the procedure medically necessary for you.
• Contact a health insurance attorney.  Most attorneys are willing to have a free phone call to discuss your situation, evaluate whether if you have grounds to sue, and assess whether a suit would be worthwhile even if you win.  In most cases a lawsuit won't be worth the cost and effort.
• Change insurers.  Non-urgent procedures allow you time to change from one insurer to another.  Just be certain your new insurer covers the procedure you need, so you don't end up in the same situation a second time.
• Pay without insurance.  Patients who pay out of pocket generally get a modest "cash-pay" discount.  (Members of Pocketero generally get a large discount.)  If you can't afford to pay for the procedure out of pocket, there are various companies that finance healthcare procedures.  If your financial circumstances are extremely difficult, charitable donations might be your best option, whether formal or through a crowdfunding platform like GoFundMe.  If your procedure is non-urgent, that is even better.  You can research the best providers and shop for the best prices.  Regardless, always try to get a written quote before your procedure to protect against surprise billing.

It can be shocking and infuriating when your insurance company won't cover an important procedure.  It might make you wonder why you pay those expensive premiums at all.  If you feel like your insurer is taking advantage of you, consider joining Pocketero and getting the best prices on healthcare when paying out of pocket.  Then you can switch to the cheapest insurance plan and not only save money, but avoid frustration.  When you control your healthcare by paying out of pocket, nobody else can dictate what's "medically necessary" for you.