Why Insurers Deny Mesothelioma Treatment
Most mesothelioma treatment denials come down to reasons like a lack of medical necessity or not having proper authorization. Insurers can withhold insurance for clinical trials or new treatments. However, several denials can be appealed and people with mesothelioma have options to complete health payments.
Common Denial Reasons
- Clinical trial-related and diagnostic costs: Clinical trial costs, PET scans and biomarker or genetic testing are denied when they are not pre-approved.
- Coding or paperwork error: The reason for a denial could be a minor error on the paperwork. This can typically be fixed with a phone call rather than filing a formal appeal.
- Newer, off-label or “experimental” treatment: Newer mesothelioma immunotherapy combination regimens may not be covered since the outcomes are not widely known.
- Not medically necessary: Insurers most commonly deny claims for this reason. What health insurance covers for mesothelioma varies, but standard plans usually cover surgery, chemotherapy, radiation and immunotherapy.
- Out-of-network specialist: Mesothelioma is rare, and the right surgeon or care center is often out of network. Insurance companies may deny coverage if you see a specialist.
- Prior authorization not obtained: Prior authorization denials often occur when a required pre-approval is missed or denied.
Patient Advocate and Medical Outreach Director Missy Miller explains, ““Insurance is a very complex thing… The benefit of using Asbestos.com is we help the patient evaluate if their insurance is actually accepted by the provider or at the hospital. And if it’s not, we guide them on what insurance plans those hospitals particularly take, and we help them with their open enrollment, get into a plan where they can actually see a specialist for mesothelioma.”
How To Appeal a Denied Mesothelioma Insurance Claim
If your insurance company denies your mesothelioma insurance claim, start by filing an internal appeal. Then, if the insurer upholds the denial, you can request an external review by an independent organization.
Read your denial letter and Explanation of Benefits (EOB) to find out the exact reason the insurer has denied your claim and the deadline it requires for submitting your appeal.
The 2 Levels of Appeal
| Level | What happens | Who decides | Best when… |
|---|---|---|---|
| Internal appeal | You ask your insurer to reconsider and submit new evidence (a specialist’s medical-necessity statement, records) | The insurance company | Always start here because many denials are overturned at this stage |
| External review (IRO) | An Independent Review Organization with no financial stake re-examines the case; the insurer must comply | A neutral third party | Your internal appeal was denied and you believe the treatment is medically necessary |
Filing an Internal Appeal
The first step in the appeal process is the internal appeal. An internal appeal is a formal inquiry to your insurer regarding your mesothelioma claim. You can request everything your insurer used to make their initial decision since this information is needed to draft your appeal.
Your appeal should include a strong letter of medical necessity from your mesothelioma specialist and your complete records. You can also request an expedited appeal, which your insurance company must review and respond to within 72 hours.
Requesting an External Review
If your insurer denies your internal appeal, you can ask an Independent Review Organization to conduct an external review. An IRO is a neutral third party with the power to overturn an insurance company’s decision about a mesothelioma claim.
Because the IRO is completely independent, the law requires your insurer to follow the IRO’s decision and approve covered care. Request a review as soon as possible if delaying your mesothelioma care poses a serious threat to your health.
Discover financial assistance programs, insurance guidance, and veteran benefits to help cover your mesothelioma treatment expenses.
Get Financial HelpHow To Write an Effective Appeal Letter
A strong appeal letter will state what was denied, why your mesothelioma treatment is medically necessary and what you’re asking the insurance company to do. While it should be concise, it is not a legal claim.
What To Include in Your Appeal Letter
- A clear request and deadline. The deadline should request an expedited review if treatment is time-sensitive.
- A medical necessity statement from your mesothelioma specialist. This is one of the most important elements of your appeal.
- Supporting evidence for your treatment, such as a pathology report, treatment guidelines, peer-reviewed support or prior records.
- The patient name, policy or member number, claim number and denial date from the letter.
- The specific treatment or service being denied and the exact denial reason provided, quoted from the letter.
It can feel overwhelming to deal with a mesothelioma diagnosis and receive pushback from your insurance company for treatments your plan should cover. You don’t have to navigate the process alone. Talk to a mesothelioma specialist who can help you get the appeal and treatment you need.
Tip: Get It in Writing From Your Specialist
A medical-necessity letter from a mesothelioma specialist is the single most persuasive document in an appeal. Ask your doctor’s office to reference current treatment guidelines.
Deadlines for Appealing a Mesothelioma Claim Denial
You generally have 180 days, which is about 6 months, from the date of your denial letter to file an internal appeal. You have roughly 4 months after the final internal denial to request an external review.
With a mesothelioma diagnosis, time is of the essence to get the treatment you need quickly. It’s important to request an expedited appeal as soon as possible. If you miss a deadline, you may need to start your claim over, which could delay your treatment.
Key Mesothelioma Appeal Deadlines
You usually have 180 days from the date of your denial letter to file an internal appeal, and around 4 months after a final denial to request an external review. Ask for an expedited review if treatment can’t wait.
Get Help With Your Mesothelioma Appeal
The Mesothelioma Center’s Patient Advocates help families understand the denial, evaluate whether a hospital or provider accepts their insurance plan, gather records, time open enrollment to find a mesothelioma specialist and pursue the appeal.
Our Patient Advocates can pursue mesothelioma appeals with you. Patient Advocate Missy Miller says,”Kim was referred to me from one of the mesothelioma specialists that I work with. When she came to me, she was extremely conflicted. She didn’t know what to do. We basically help her navigate the insurance process. So when it became open enrollment, we were able to make sure that she got on her husband’s insurance that actually had the doctor that she wanted to see as an approved provider so that way she was able to have her surgery done through her husband’s insurance.” When your coverage falls short, we can help you seek financial assistance, grants and legal compensation to help pay for your care.
Exclusive Content
Missy Miller, Medical Outreach Director: Why is it easier to have Asbestos.com help mesothelioma patients find insurance coverage?
One of the benefits calling me for me to help you with it as I’ve been doing this for twelve years, so I understand how complex the process is. I can actually do the research for you and find out what insurance different hospitals accept, what doctors are actually approved as providers, and make sure that you have the proper plan that you need so you can get the actual care that you deserve.
Insight From a Mesothelioma Specialist
“Insurance is extremely, extremely complicated. One of the benefits of calling me to help you with it. I’ve been doing this for twelve years, so I understand how complex the process is. I can actually do the research for you and find out what insurance different hospitals accept, what doctors are actually approved as providers and make sure that you have the proper plan that you need so you can get the actual care that you deserve.”
Missy Miller, Medical Outreach Director
Speak with a dedicated Patient Advocate for answers about treatment, doctors, and financial help.
Talk to an AdvocateCommon Questions About Mesothelioma Insurance Denials
- Is it worth appealing a denied mesothelioma insurance claim?
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Yes. Many denied mesothelioma claims are overturned, especially when a specialist documents that treatment is medically necessary. There is no cost or penalty to appeal the insurer’s decision.
- What are the odds of winning an insurance appeal?
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A large share of appeals are successful, and external reviews conducted by an independent organization overturn denials more often than patients expect. If you or a loved one with mesothelioma receives a denial with an internal appeal, get an external review as soon as possible.
- How long does a mesothelioma insurance appeal take?
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It depends on the level of appeal. Internal appeals are usually faster than external reviews, and reviewers can decide expedited or urgent appeals quickly when mesothelioma treatment can’t wait. You can request an expedited review to move the process along and get the care you need.
- Do I need a lawyer to appeal a health insurance denial?
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No. You can appeal on your own. A free patient advocate or your doctor’s office can help you compile all the evidence. You usually do not need a lawyer for a health insurance coverage appeal.
- What can I do if my appeal is denied and I still can’t afford treatment?
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There are other ways to afford treatment, including financial assistance, grants, manufacturer and nonprofit programs and legal compensation tied to asbestos exposure. Each of these can help you cover the costs. Our patient advocates can get you started with free help to navigate the process.
