Medical Insurance Claim Denied
An outline to fight back that worked for me
Yesterday, I received written confirmation from my medical insurer that I had successfully challenged their initial denial of a recently engaged medical service in conjunction with my recovery from severe COVID this past September. Part of my recovery entailed a cardiology consult due to a maddening bout of paroxysmal nocturnal dyspnea. In addition to the in-office ECG, cardiology ordered a modern-day Holter monitor by Zio for a one week duration to assist in diagnosis.
The claim for the device and the data extraction service was initially denied without indicating a reason other than “non-covered service”. So I wrote this appeal letter and filed it with the insurance grievances department. It worked. Hopefully this approach can help others. Plagiarize as much as you’d like!
“Experimental Procedure”
I am writing to appeal the denial of <claim> dated 10/19/2021. First, this was not an experimental procedure. The Zio XT monitor is merely a modern day equivalent to the Holter monitor, a groundbreaking device that has been used in cardiology since 1962 to record cardiac events that cannot be captured during a 30-second in office ECG.
“Not Medically Necessary”
Second, this was a medically necessary procedure. Having previously been diagnosed with endocarditis, my cardiologist ordered this monitor to help determine the cause and proper treatment of the acute bradycardia/tachycardia and paroxysmal nocturnal dyspnea I was experiencing during the month of September 2021, likely exacerbated by severe COVID-19. The fact remains ventricular arrhythmias and tachycardias MUST be treated differently from sinus rhythm tachycardias. In fact ventricular arrhythmias and tachycardias are life threatening conditions. It is impossible for an office ECG to capture an episode of tachycardia that occurs away from the test as happened during multiple instances in my case. The in-office ECG failed to detect a tachycardic episode in which my resting HR elevated to 161 BPM from baseline of 58 BPM for no apparent reason while driving a vehicle. The Zio XT monitor chronicled the event, listed all supraventricular tachycardias and other ectopic events, and greatly assisted in proper diagnosis. This data, which was impossible to obtain without the monitor, finalized the diagnosis and treatment prescription.
“Non Covered Services”
Third, the Zio XT was ordered in lieu of using more expensive diagnostic options like an echocardiogram to rule out COVID-19 induced myocarditis and pericarditis. The device actually saved <insurer> from paying for more expensive imaging and labs.
“Not Routine Standard Of Care”
Lastly, the order was consistent with established medical practice. In the article titled Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guidelines for diagnosis and management published in September 2020 Heart Rhythm, the authors state the following:
“Clinical presentation of SARS-CoV-2 myocarditis varies among cases. Some patients may present with relatively mild symptoms, such as fatigue and dyspnea, whereas others report chest pain or chest tightness on exertion. Many patients do deteriorate, showing symptoms of tachycardia and acute-onset heart failure with cardiogenic shock. In these severe cases, patients may also present with signs of right-sided heart failure, including raised jugular venous pressure, peripheral edema, and right upper quadrant pain. The most emergent presentation is fulminant myocarditis, defined as ventricular dysfunction and heart failure within 2–3 weeks of contracting the virus. The early signs of fulminant myocarditis usually resemble those of sepsis: the patient often presents febrile with low pulse pressure, cold or mottled extremities, and sinus tachycardia.”
Recognizing the clinical manifestations of viral or immune induced cardiac inflammation, my cardiologist deemed this a medically necessary procedure in order to correctly diagnose my condition.