What to do if insurance denies your MG treatment

If you have myasthenia gravis (MG) and have been denied MG treatment by your insurance, you’re not alone. An MG treatment insurance denial can sometimes feel like you’re running up against a brick wall.

But while insurance denials can be frustrating and stressful, they’re not the end of the road. Here’s what you should know if your insurance denies MG treatment.

Why MG treatments are sometimes denied

Health insurance companies deny claims for many reasons, and it’s not always because the treatment isn’t appropriate for you. Treatments may be denied because:

• The treatment isn’t a covered benefit under your health plan.
• Your insurer says the treatment coverage requested is “not medically necessary” or “experimental.” In this case, your insurer may require documentation from your doctor justifying the treatment or therapy.
• There was no prior authorization obtained for the MG treatment, nor was preapproval granted.
• You hit a coverage limit.
• There were administrative issues, like coding errors or using an out-of-network provider.

These denials often reflect how insurance coverage for MG is defined in your specific health plan, rather than whether the treatment is appropriate for you.

Review the denial letter carefully

When your insurance denies a claim, the company is legally required to send a written notice explaining the reasoning.

This health insurance denial letter should be read carefully. It will explain what treatment was denied, why it was denied, and how long you have to formally appeal an insurance denial for MG.

Contact your healthcare provider right away

As soon as you receive a denial, reach out to your MG care team.

Not only can your neurologist or care team help interpret the insurer’s denial reasoning, but they may also be able to provide crucial documentation, such as a letter of medical necessity for MG treatment or additional clinical records, to appeal on your behalf.

File an insurance appeal

Understanding your options in the MG insurance appeal process is key.

If your doctor hasn’t directly appealed, you can initiate an appeal. This is a formal request to your insurer asking the company to reconsider the denial.

Most insurance plans have an internal appeal process that involves sending an appeal letter, which should include why you need the medical service for which you were denied coverage.

You can also include a letter of medical necessity from your doctor, second opinion letters vouching for the treatment coverage requested, and any research (from clinical journals or official treatment guidelines) that supports why the treatment would be good for you.

If you are denied again, you may be entitled to something called an external appeal. This is where an independent reviewer comes in to assess your appeal.

Ask about temporary or alternative support

If your treatment was denied, or if you’re stuck in appeals process limbo, your doctor can potentially prescribe alternative therapies in the interim.

It’s worth researching which alternative treatments are available to you, whether your insurance covers them, and what the cost to you would be. Your doctor may also be able to speak directly with your insurance company about alternative options.

When to seek additional help

There is nothing wrong with asking for help when navigating insurance with MG. You have a plethora of options: MG patient advocacy support organizations, disease foundations, and consumer assistance programs often offer resources and even direct assistance with appeals.

You may also want to reach out to a patient advocate service or an attorney with experience in insurance law to help you understand your rights and determine your next steps.

Some advocacy groups and assistance programs can also assist you in finding help paying for MG treatment, especially while an appeal is pending.

Lastly, you can formally authorize a family member or caregiver to help with insurance appeals, or appoint a patient advocate or attorney to act as your representative. To do this, contact your insurance company to get the proper forms.

Once you fill these forms out and send them in, you’ll be able to have a designated representative speak on your behalf.