PHA Case Study – Coverage denied for an experimental treatment


Mike had a Metatarsophalangeal Joint (MPJ) replacement surgery that his insurance company consideredexperimental and therefore did not cover. He appealed, but coverage was denied. Working on his behalf, his Personal Health Advocate gathered research documentation about the surgery and drafted a letter to submit to an Internal Review Office for review. The denial was subsequently overturned based on the research supporting the benefits of the procedure. This saved Mike over $11,000 in hospital fees. Soon after, the insurance company updated their medical policy to cover surgery for certain procedures they did not previously cover.

What The Healthcare Survival Guide Says:

Talk with both your doctor and insurance company about your treatments before services are rendered to make sure you are covered. Watch out for condition exclusions relating to certain conditions – some plans may specifically exclude coverage for heart disease, cancer, or pregnancy, for example (pg. 26). If you do have a pre-existing condition and were previously covered before job termination, you can’t be discriminated against for healthcare coverage (pg. 24). If you have a chronic, life-threatening, and/or debilitating disease, the Patient Advocate Foundation (PAF) can help you with a range of healthcare issues, including insurance appeals and patient education (pg. 37).


One Response to PHA Case Study – Coverage denied for an experimental treatment

  1. We’re very happy to have helped! What type of work does your organization do?

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