How to get the medical policy your insurer used to deny you
Most insurers publish their clinical policy bulletins online. Here is how to find the exact policy that drove your denial and use it in your appeal.
Find the bulletin
The denial letter must cite the rule or policy. The letter usually names the policy number or coverage determination.
Search the insurer's site for 'clinical policy bulletin' or 'medical policy' plus the procedure or drug name.
ERISA requires the plan to provide the policy on request, free of charge.
Use it in your appeal
Map your records to each criterion in the policy by line.
Where a criterion is not met, explain why an exception applies (contraindication, prior failure, specialist judgment).
Upload the denial letter. Free analysis first, finished letter second.
FAQ
What if the insurer will not send the policy?+
File a written request citing 29 CFR 2560.503-1 for ERISA plans. Failure to provide it is itself a basis for appeal.
More guides
- How to write a health insurance appeal letter
- Internal appeal vs external review: what is the difference
- Expedited appeals: when to ask for an urgent review
- The No Surprises Act and out-of-network bills