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Insurance denied: experimental or investigational. How to appeal
Your health insurance denied a claim as experimental or investigational. What it means, your deadline, and how to appeal.
Check my letter freeWhat it means
The plan says the treatment is not proven for your condition.
What to do
Ask your doctor for a letter with the medical studies that support the treatment.
If the plan says no again, you can ask for an external review by independent doctors.
Your deadline
Most plans give you 180 days from the denial notice to file an internal appeal. Original Medicare gives 120 days from the Medicare Summary Notice, and Medicare Advantage plans 65 days from their decision. Check the date printed on your letter.
If the plan says no again
After a final denial from a marketplace or employer plan, you can ask for an external review by an independent reviewer within 4 months. If the reviewer decides for you, the plan must pay.
Ask for your claim file
You have the right to receive, free of charge, copies of the documents and the criteria used to decide your claim.
Other denial reasons
- Not medically necessary
- No prior authorization
- Out of network
- Billing or coding error
- Not covered by your plan
- Claim filed too late
- Other insurance (coordination of benefits)
- Coverage not active