SAMPLE LETTER TO SEND TO INSURER
If you have been denied insurance reimbursement this letter designed to go to your insurance company may assist you with resolving some of your issues. Please feel free to adjust it to fit your circumstances.
Insurance Company Name
Attorney General’s name for your state
To whom it may concern,
I am writing today to respectfully request a copy of any policy, criteria, guideline, document, record or other information referenced in making the determination to abruptly deny my health care coverage. Please include the names of any medical and/or financial experts whose advise was obtained on INSURANCE COMPANY behalf in connection with the determination regarding the denial of my claim for benefits.
Your recent denial letter stated, (EXAMPLE BELOW)
"The medical documentation provided fails to substantiate a diagnosis of Lyme Disease consistent with the criteria set by the CDC.”
Please note the following documentation, directly from the CDC:
CDC, July 1999:
The “CDC has no specific program dealing with "chronic" Lyme disease. CDC Lyme disease program focuses on the surveillance, epidemiology, prevention and control of Lyme disease, and does not have a treatment protocol or guidelines on management of LD patients."
"This surveillance case definition was developed for national reporting of Lyme disease; it is NOT appropriate for clinical diagnosis."
"This surveillance case definition was developed for national reporting of Lyme disease; it is not intended to be used in clinical diagnosis."
"The usefulness of public health surveillance data depends on its uniformity, simplicity, and timeliness. The case definitions contained in this report establish uniform criteria for disease reporting and should not be used as the sole criteria for establishing clinical diagnoses, determining the standard of care necessary for a particular patient, setting guidelines for quality assurance, or providing standards for reimbursement. Use of additional clinical, epidemiologic, and laboratory data may enable a physician to diagnose a disease even though the formal surveillance case definition may not be met."
In addition, the IDSA Lyme treatment guideline panel members were recently investigated by the Attorney General and found guilty of having multiple conflicts of interest directly related to the development of their diagnostic and treatment guidelines. Their Lyme disease guidelines are no longer recommended, nor endorsed by the CDC. The IDSA panel members have been restricted from participating in the development of future guidelines. The tainted IDSA guidelines are currently in the process of being reviewed and rewritten for medical and scientific accuracy by a new independent panel and overseerer under the direction of the Attorney General’s office.
The CDC has recently issued a disclaimer on their website for the IDSA Lyme treatment guidelines, stating:
The IDSA guidelines are undergoing review and will be updated if necessary. We have provided a link to this site because it has information that may be of interest to you. CDC does not necessarily endorse the views or information presented on this site. Furthermore, CDC does not endorse any commercial products or information that may be presented or advertised on the site that is about to be displayed.”
Some insurance companies have adopted guidelines reflecting short-term treatment approaches. However, the legal standard of care for treating a condition is determined by the consensus of physicians who actually treat patients, not by treatment guidelines.
Please note- patient preference exists whenever there is more than one acceptable treatment approach. The American Medical Association requires that the patient’s physician disclose and discuss with the patient not only the risks and benefits of the proposed treatment, but also the risks and benefits of available alternative treatments (regardless of their cost or the extent to which the treatment options are covered by health insurance).
The International Lyme and Associated Diseases Society (ILADS) has issued the only peer-reviewed treatment guidelines, approved by the AMA, which covers the diagnosis and treatment of chronic Lyme and tick borne diseases. My physician has explained the benefits and risks to me and I have elected to follow the International Lyme and Associated Diseases Society (ILADS) Lyme Treatment Guidelines.
As for the statement you made regarding additional tests.< EXAMPLE
The CDC states:
"Not all LD patients present with typical manifestations; other conditions might be confused with LD and laboratory testing might be inaccurate."- Centers for Disease Control MMWR, January 18, 2002 / 51(02);29-31
The central difficulties in the diagnosis and treatment of Lyme disease stem from the lack of sufficiently sensitive and reliable biological markers of the disease. Without such markers, it is difficult to determine who has the disease, the effectiveness of a course of treatment, and the end point of treatment.
In fact, Johns Hopkins Medical Institute states in their study:
“Although cultivation of Borrelia burgdorferi is deﬁnitive, prior investigations have shown that no single test is optimal for Lyme disease diagnosis.”
Two-Year Evaluation of Borrelia burgdorferi Culture and Supplemental Tests for Deﬁnitive Diagnosis of Lyme Disease- Coulter,1 Lema,1 Flayhart,1 Linhardt,1 Aucott,2 Auwaerter,2 and Dumler1* Division of Medical Microbiology, Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland,1 and Divisions of General Internal Medicine and Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland, 13 July 2005
The Hopkins study determined approximately 75 percent of the people tested for Lyme disease are missed using the standard tests. The CDC, NIH, FDA, Yale, Mayo Clinic, Hopkins, ILADS, IDSA and many additional medical and scientific organizations have each concluded the tests for Lyme disease miss many cases, as many as 75% to 90% of those who have Lyme disease. The CDC concluded years ago that Lyme is to be diagnosed clinically and tests should never be used to rule out the infection.
The CDC website clearly states:
“Lyme disease is diagnosed based on symptoms, objective physical findings (such as erythema migrans, facial palsy, or arthritis), and a history of possible exposure to infected ticks. Validated laboratory tests can be very helpful but are not generally recommended when a patient has erythema migrans.” http://www.cdc.gov/ncidod/dvbid/lyme/ld_humandisease_diagnosis.htm
In light of the facts above, if you continue to deny benefits, I also request the following documentation:
1. The specific reason or reasons for the adverse determination.
2. References to the specific plan provisions on which the determination is based.
3. A description of any additional material or information necessary for me to perfect the claim and an explanation of why such material or information is necessary.
4. A description of the plan’s review procedures and applicable time limits, including whether I have a right to bring a civil action following an adverse benefit determination on review.
5. If an internal rule, guideline, protocol or other similar criterion was relied upon in making the adverse determination, I request a copy of the specific rule, guideline, protocol or other criterion and the author’s credentials.
6. If the adverse benefit determination is based on a medical necessity, experimental treatment or a similar exclusion or limit, please provide an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to my medical circumstances.
7. All internal rules, guidelines, protocols, etc. referenced or relied upon in making the adverse determination.
8. All records, notes and summaries of phone calls.
9. All communications regarding my case.
10. All correspondence relating to me, including, but not limited to correspondence to and from my treating physicians and/or home health care provider.
11. All information from third party sources, such as consultants.
12. All reviews conducted by the insurer’s medical personnel.
13. All medical reviews conducted at the request of INSURANCE COMPANY.
14. The identity and credentials of all medical personnel who reviewed my claim.
15. All reports produced at INSURANCE COMPANY regarding my claim.
16. The names, credentials and notes of all reviewers.
17. Any and all other documented medical, financial or other information that may have influenced INSURANCE COMPANY to deny my claim.
18. A copy of any medical records referred to in making the adverse determination.
19. A copy of any medical or financial reports and documents generated before, during or after your most recent merger, sale or buy out regarding employees benefits, cost saving plans and/or insurance related matters.
20. A list of contacts and a copy of contracts with physicians or health care providers associated with and/or approved by you who have experience with or who have successfully treated patients with one or more acute and/or chronic/late stage tick borne infections.
Please respond to this request in writing within 30 days and send the above documentation directly to me at the following address:
Your name and address
YOUR NAME SIGNED HERE
CC: Name of CEO for your insurance company, YOUR DOCTOR’s Name, Other Insurance Company Name if you have any, YOUR Attorney General, YOUR State Department of Insurance, YOUR State Department of Labor, NCQA, URAC, YOUR state legislative representatives, Congressional Senator XX AND Senator XX, YOUR Congressional House member, any others you feel should be informed.