Nobody can tell you that an insurance payer will overturn its own denial each and every time an appeal is brought by a patient.
However, under most fully-insured and self-insured health plans today patients have the right, once they complete the entire internal appeals process, to have an adverse benefit determination (denial) reviewed by a professional who is completely separate from the insurance company denying the claim. This is called an “Independent Review” and the accredited companies responsible for administering these reviews are called Independent Review Organizations (IRO) and must meet certain standards required to ensure patients get a full and fair review of denied claims.
One of the major benefits of having our office help you is that we are constantly setting your case up to be in the best possible position to get approved by an IRO, even if it does not get approved by the insurance plan. By us knowing the difference between what information and documentation an insurer is looking for to approve a case versus what the IRO reviewers are looking for to overturn a decision, we can constantly assess your case right from the start and in doing so make the difference between you having the surgery or treatment you need or not having it.
Most often patients can only use the IRO process when the insurer’s denial is based on the treatment not being medically necessary (or does not meet the payer “medical criteria”), or that the procedure is experimental or investigational. There are occasions where the IRO might consider whether or not a treatment claimed by the payer to be excluded should be overturned, but for the most part contract-based denials such as exclusions for weight loss surgery are outside the IRO process.
When a denial is brought to them by our office, and is confirmed by them that it is an appropriate case for the IRO process, the agency will select an impartial medical expert who will review all appropriate documentation to determine whether or not the treatment which has been denied should be approved. This medical expert is not bound by the same medical criteria often used by the insurance payer to deny the claim in the first place. For example, an insurance company might require a weight loss surgery patient to complete a six-month medically supervised weight loss program as part of its medical policy to show surgery is “medically necessary.” The IRO reviewer is free to disregard that six-month weight loss criteria, knowing that there is little evidence-based medicine in support of that process and can approve the case despite the lack of documentation of such a program.