As promised, today I am providing you with the text of two different letters of appeal that I wrote when reimbursement for my cranial prosthesis (a.k.a. wig) was denied by my insurance company. I did not know much about purchasing “durable medical equipment” when I made the purchase, and simply thought that any cranial prosthesis provider that I was referred to by my care team would be covered.
I shake my head today at how naïve I was at the time. But, I was going through chemotherapy and radiation, working two jobs, and caring for my family. I suppose I can forgive myself for not thinking straight!
And in the end, it all worked out. The reason for the high cost of my wig was that it was made out of real human hair. It was beautiful. So close to my natural hair color, long bangs, a few wispy grays that made it look all the more natural. No one who saw me in it could tell that I was wearing a wig. I loved the anonymity it afforded me.
I bought it in a bit of a rush, when I learned that you should actually shop for wigs before you lose your hair – that way, the stylist can match the wig to your own hair. The custom hair store, referred to here simply as “Custom Hair,” assured me that the high cost would be covered by insurance.
I had never bought a wig before. I didn’t know that wigs came in every price range, from $25 to $10,000.
I also did not know that the appropriate medical term is “cranial prosthesis.” Don’t call it a “wig,” I was told. Call it a “cranial prosthesis.”
Six months after I purchased the cranial prosthesis, once chemotherapy was over and radiation had begun, I learned that my insurance company had denied my claim to pay for the prosthesis. A prosthesis that I had paid for out-of-pocket, anticipating reimbursement.
This is the letter that I then wrote.
First Level Appeal:
May 8, 2019
RE: [Insurance] Claim Number XXXXXXXXXXX
To Whom it May Concern:
I write to appeal Claim Number XXXXXXXXX, with a date of January 5, 2019. This is a claim from the purchase of a cranial prosthesis from Custom Hair, used during and after my chemotherapy treatment for breast cancer.
According to the “Benefit Summary” provided to me by my employer, “Durable Medical Equipment” is covered at 80% coinsurance after plan deductible is met, and out-of-network providers are covered at in-network levels. A cranial prosthesis is considered “Durable Medical Equipment,” and since I have already met my out-of-pocket limit for the year, should be covered at 100%.
I purchased my cranial prosthesis out-of-pocket from Custom Hair, [website] which is a provider of these products specifically for women losing their hair as a result of cancer treatment, like me. I was referred to this location by my medical oncologist’s office at my hospital, who also checked with [Insurance] to ensure that my plan covered the purchase of a cranial prosthesis.
According to the Custom Hair website,
“We issue detailed receipts complete with medical coding. This receipt is then sent to the insurance company. Then our clients are reimbursed for the entire cost of their wig (if it is covered). Cranial Prosthesis and Wigs Insurance coverage is possible! Once your insurance determines that is it covered you will get a check from your insurance company. It is as simple as that!”
At this time, [insurance company] website shows that I am responsible for $175 of the cost of the prosthesis, but does not show that [insurance company] is covering the rest of the cost. So, I request that the amount of $2,995.00 be reimbursed to me by [insurance company], as this is the amount that I paid for the cranial prosthesis out-of-pocket as demonstrated by the enclosed receipt.
Kind regards,
[Name]
Enclosures:
Medical Claim Form
Requisition
Custom Hair Receipt
This letter, written as I lost my eyebrows just weeks after my chemotherapy treatments ended, was responded to with a letter of denial from the insurance company. When I called the insurance company to inquire about it, I talked to a very kind and helpful representative who told me to write how I felt.
Write how I felt! I had not thought about this before! I tried to be practical, to reason, to cite the literature as I have been trained when making an argument. I completely forgot about the power of pathos. In my second appeal letter four months later, I wrote how I felt. Here is the second letter.
Second Level Appeal:
[Insurance Company]
Grievances and Appeals
[Address]
August 9, 2019
RE: Claim Number XXXXXXXXXX
Case Number XXXXXXXXXXXX
To Whom it May Concern:
I recently received the first level appeal decision denying this appeal, and I write to ask for a second level appeal.
Again, claim number XXXXXXXXX, with a date of January 5, 2019, is a claim from the purchase of a cranial prosthesis from Custom Hair, used during and after my chemotherapy treatment for breast cancer.
According to the “Summary of Benefits” provided to me by my employer and included here, “Durable Medical Equipment” is covered at 80% coinsurance after plan deductible is met, and out-of-network providers are covered at in-network levels. Please see the included plan documents from my employer that indicate this coverage. A cranial prosthesis is considered “Durable Medical Equipment,” and since I have already met my out-of-pocket limit for the year, should be covered at 100%.
I purchased my cranial prosthesis out-of-pocket from Custom Hair, [website] which is a provider of these products specifically for women losing their hair as a result of cancer treatment, like me. I was referred to this location by my medical oncologist’s office at my hospital, who also checked with [insurance company] to ensure that my plan covered the purchase of a cranial prosthesis.
According to the Custom Hair website,
“We issue detailed receipts complete with medical coding. This receipt is then sent to the insurance company. Then our clients are reimbursed for the entire cost of their wig (if it is covered). Cranial Prosthesis and Wigs Insurance coverage is possible! Once your insurance determines that is it covered you will get a check from your insurance company. It is as simple as that!”
Between this assurance from the businesses’ website and [insurance company] reassuring me that a cranial prosthesis was covered by my policy but never informing me of a maximum allowable amount, I felt confident that I could choose a provider recommended by my hospital and particularly for women facing cancer treatment when choosing a prosthesis to help me manage to work and provide income and medical coverage for myself and my family during my cancer treatment. I had no other choice. As you might imagine, I was not experienced in purchasing a prosthesis, and went with the guidance of my insurance company and my healthcare provider. To now face an almost $3,000.00 expense is an immense burden atop the burdens of healing from surgery, chemotherapy, and radiation, while also serving as the sole provider for my husband and two little girls. I would hope that insurance and healthcare providers will work together more effectively in the future to prevent other cancer patients from suffering these additional worries on top of the anxiety caused by treatments.
I respectfully request that you reimburse to me the total cost of the cranial prosthesis that I purchased, $2,995.00. I would also ask that policies regarding Durable Medical Equipment be more clearly communicated to patients in similar situations to mine. Dealing with unexpected costs and insurance headaches should not be part of the journey that is cancer and its treatment.
Kind regards,
[Name]
Enclosures:
Medical Claim Form
Requisition
Custom Hair Receipt
Health Plan Summary of Benefits
This letter was successful. Shortly after I received a check for the complete amount of the prosthesis. A combination of research and logic, along with feeling, did just the trick. Dealing with insurance can be a painful process, as I’ve written elsewhere. But honest and heartfelt appeals can make a difference.
If you or someone you know is facing an appeal process for an uncovered claim, feel free to use this letter as a template.