Insurance Letters of Appeal

Introduction

Unfortunately denial of coverage for lymphedema treatment is an all too common experience. You can submit a letter requesting a review of this denial, but what can you say that is convincing? Here are some ideas that might help!

Primary Points

Your letter should cover these three primary points: 

(1) Clarify that this is a physician ordered treatment.

(2) Explain lymphedema.

(3) If appropriate, cite the Federal Women’s Health and Cancer Right Act.

Physician Ordered Treatment

The following excerpt from a letter written by a Lymph Notes member clarifies that this is physician ordered treatment. (Her letter worked and she received the necessary treatment!)

“As instructed on June 12, 200X, by my oncologist, John Doe MD, I am currently seeking physical therapy treatment for swelling and pain in my right arm caused by lymphedema. By this document, I am notifying you that Dr. Doe diagnosed lymphedema in my right arm as a result of having a mastectomy and lymph nodes removed from my right armpit due to breast cancer.

"The treatment for this chronic condition is complete decongestive therapy administered by a qualified therapist who is certified in lymphedema treatment. Jane Smith my physical therapist at the Women’s Health Center (WHC) is a certified lymphedema therapist. As per your previous instructions, WHC has already submitted to you Dr. Doe’s current prescription ordering ongoing treatment for this chronic condition.”

Explain Lymphedema

The following explanation of lymphedema is brief and effective. It is important to include the source of this quote which is from "The Diagnosis and Treatment of Peripheral Lymphedema: Consensus Document of the International Society of Lymphology." Lymphology 23 (2003) 84-91. [2]

“Because lymphedema is a chronic, generally incurable ailment, it requires, as do other chronic disorders, lifelong care and attention along with psychosocial support. The continued need for therapy does not mean that treatment is unsatisfactory. For example patients with diabetes mellitus continue to need insulin or a special diet. Similarly, patients with lymphedema require lifelong care.”

Women’s Health and Cancer Rights Act (WHCRA)

This federal law mandates that group health plans provide some treatment of lymphedema. [3] Mentioning this law can be helpful in your appeal. Our letter writer includes information for use by breast cancer patients.

“By limiting the number of physical therapy treatments and thereby denying me medical coverage for complications due to breast cancer, the (your health plan name here) is in violation of the federal Women's Health and Cancer Rights Act (WHCRA) of 1998 that was signed into law on October 21, 1998 by the 105th Congress.

“It is called Public Law #105-277. It appears as provision Title IX under Subtitle IV of a much larger Omnibus bill, HR 4328. It is, in fact, this bill that passed, which included the WHCRA, and mandates that ALL insurance companies and HMOs provide coverage for "physical complications of mastectomy including lymphedemas."

If this federal law applies to your situation, you may want send copies of your letter to your senators and representatives in Congress.

Caution: If you are a breast cancer patient covered by Medicare, this law no longer protects you. Instead you must cope with Medicare regulations!

Wrapping up Details

When you write a letter of appeal, be certain to keep copies of all correspondence. Also keep a record of any phone conversations you have. Note the date, the name of the person you spoke to, and the key points of the conversation.

References

[1] Living Well with Lymphedema by A. Ehrlich, A. Vinjé-Harrewijn PT, CLT, and E. McMahon PhD. Lymph Notes, 2005, Chapter 5, pages 57-72.

[2] The Diagnosis and Treatment of Peripheral Lymphedema: Consensus Document of the ISL.

[3] Women’s Health and Cancer Rights Act.

© LymphNotes.com 2006. This information does not replace the advice of a qualified health care professional.

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Category: Insurance and Medicare Updated: 2006-04-14