Healthcare Helpline: Navigating Insurance Denials for Preventive Tests

When your healthcare provider recommends a preventive test, but your insurance denies coverage, it can be a frustrating experience. Many families face this challenge, especially with services like hearing tests, which are often indicated as essential by physicians but still get rejected by insurers. Take Anna Deutscher's story: her infant son Beckham was diagnosed with congenital CMV, requiring regular hearing assessments until he turns ten. Despite the tests being classified as preventive care, her insurance repeatedly denied coverage, leaving the family to pay approximately $350 per test out of pocket, eventually maxing out their credit cards.

Understanding your insurance policy is the first step. Review your plan documents carefully to confirm if the service is covered and note any exclusions. Even if a service is initially denied, it doesn’t necessarily mean it’s permanently excluded.

Second, determine if the service qualifies as preventive care. Under the Affordable Care Act, many preventive services are covered at no extra cost. However, some plans are grandfathered and may have different protections. Insurance expert JoAnn Volk emphasizes that interpretation differs between providers and plans, so direct communication is crucial.

If a service is denied, it’s important to understand why. Insurance companies are required to specify the reasons, such as coverage exclusions or medical necessity issues. Use this information to formulate an informed appeal. Gather relevant medical records, test results, and guidelines that support the preventive nature of the service. Sometimes, a letter from your physician explaining why the service is vital can make a significant difference.

Filing an appeal generally involves requesting a review through your insurer. Follow the process outlined in your explanation of benefits, submit a written disagreement, and include supporting documents. Most insurers have 30 to 60 days to respond, and if the initial appeal is denied, you can often escalate the case for external review by a medical professional.

Engaging your employer's human resources department can also prove advantageous. HR professionals may have established contacts with insurers and can advocate on your behalf. Deutscher’s experience highlights that involving HR led her employer to cover her son's hearing tests and ultimately motivated her company to include hearing screenings as a standard benefit.

Navigating insurance denials involves persistence and understanding. By knowing your policy, questioning denials, and seeking external help, you can improve your chances of receiving coverage for essential preventive tests. For additional support and guidance, visit healthcare.gov or your state insurance department.

Source: https://medicalxpress.com/news/2025-08-health-helpline-doctor.html