The Use of Evidence Based Medicine in Appeal Letter Templates

Insurance company denials of payment are rarely issued in a random and infrequent manner. Most denials for services rendered are grouped around specific issues on payment policies, as defined by the insurance carrier. As an appeal writer, it only makes sense to develop appeal letter templates that will hold the supporting arguments for payment and can be used for each of the various issues.

Using an appeal letter template allows for increased efficiency in performing appeal work. The research of each insurance carrier’s payment policy is completed once at the time the template is developed. By tailoring the appeal argument to each specific issue that the payer has identified as the reason for the denial, it eliminates the need to write each appeal from scratch.

One of the first tasks that must be completed when creating an appeal template is to understand the insurance payer’s language. It’s important to understand the payer’s definitions of “medical necessity” and “reasonable and necessary.” These are the basis for the vast majority of reasons to deny. It’s equally important to include the payer-specific language for medical necessity in the appeal template. This allows the appeal writer to use the template to help determine whether the medical record meets the payer’s requirements for documentation of payable services.

Remember, the appeal writer does not have to research the payer definitions in order to use the payer’s language in the argument as it is already supplied in the template. Most payers use similar language to define medical necessity of services. Using each payer’s own language in the payer-specific template ensures the appeal arguments are precise in refuting the payer’s decision to deny payment.

When defining medical necessity, most payers base their payment policies on services that are provided according to the standard of care in the medical community. This standard of care is generally defined as the incorporation of evidence-based medicine and guidelines into appropriate medical care. It’s beneficial if the research for appropriate evidence based guidelines that support the standard of care is done in advance. It’s even fine if the research is done at the time of writing the first appeal letter for a given issue and incorporating it into a template. This allows all appeal writers the ability to take advantage of the templated research.

The best research evidence can come in many forms. These can include peer-reviewed, published medical journal articles, a review of available studies on a particular topic, evidence-based consensus statements, expert opinions of health care professionals or guidelines from nationally recognized health care organizations. The Institute of Medicine defines clinical practice guidelines as such:

“Clinical Practice Guidelines are statements that include recommendations intended to optimize patient care. They are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”

From the Institute of Medicine’s, “Clinical Practice Guidelines We Can Trust”

Most payers will define or provide examples of what types of published literature or research they consider acceptable as supporting the standard of care in the medical community. That doesn’t necessarily prevent the use of literature outside of the payer’s “list” to argue medical necessity. Yet, any clinical practice guideline or evidence-based medicine guideline needs to stand the test of whether it is accepted as the standard of care in the medical community.

One model often copied by commercial payers is Medicare. This is what they say about acceptable standards of care in the medical community:

“Medicare contractors, in determining what “acceptable standards of practice” exist within the local medical community, rely on published medical literature, a consensus of expert medical opinion, and consultations with their medical staff, medical associations, including local medical societies, and other health experts. “Published medical literature” refers generally to scientific data or research studies that have been published in peer-reviewed medical journals or other specialty journals that are well recognized by the medical profession, such as the “New England Journal of Medicine” and the “Journal of the American Medical Association. By way of example, consensus of expert medical opinion might include recommendations that are derived from technology assessment processes conducted by organizations such as the Blue Cross and Blue Shield Association or the American College of Physicians, or findings published by the Institute of Medicine.”

So, how are you incorporating evidence based medicine guidelines into your appeal letter templates?