My insurance said a procedure is investigational, but my doctor says it’s standard of care?
An insurer denies a standard procedure as “investigational” because its coverage decisions run on a cost-benefit analysis of limited health care dollars. They do not run on what your doctor considers the standard of care. The denial can be appealed, and the appeal clock is short.
As a physician, my patients often ask me why a procedure that is standard medical treatment might be denied as investigational. Even stranger, some private insurance companies will approve a procedure under one plan. Then they will deny the same procedure as investigational under a different plan. Both plans are run and owned by the same company.
The reality is that health care dollars are limited. Insurance companies run a cost benefit analysis on their coverage decisions. They weigh that against a possible public relations backlash. They also weigh the hassle of State insurance Board appeals and scrutiny. Always check with your physician’s office and your insurance carrier. Your appeal rights are time limited, so pay close attention to any requests for information. Unless you have signed an ABN [Advance Beneficiary Notice], you may not have to pay a bill that the insurance company denies as investigational.
Frequently asked questions
What does “investigational” mean in insurance?
It is the label an insurer puts on a procedure it has decided not to pay for, even when your doctor considers it standard medical treatment. Health care dollars are limited. Insurers run coverage decisions through a cost-benefit analysis. They weigh it against possible public relations backlash and the hassle of State insurance Board appeals and scrutiny. The label reflects that analysis, not your doctor’s standard of care.
Why would the same insurance company approve a procedure under one plan and deny it under another?
Because each plan carries its own cost-benefit decision. Some private insurers approve a procedure under one plan. Then they deny the same procedure as investigational under a different plan, even when the same company owns and runs both. The medicine did not change between the two plans; the coverage decision did.
Can I appeal a procedure denied as investigational?
Yes, but your appeal rights are time limited. Talk with your physician’s office and your insurance carrier as soon as the denial arrives. Pay close attention to any request for information, because a missed deadline can close the appeal.
Do I have to pay a bill my insurance denied as investigational?
Not always. Unless you signed an ABN (Advance Beneficiary Notice) before the procedure, you may not have to pay a bill that your insurance company denies as investigational. Check with your physician’s office and your carrier before you pay.
Medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP — Board Certified in Anesthesiology, Pain Medicine, Interventional Pain Management, Addiction Medicine, and Obesity Medicine.
