r/mildlyinfuriating • u/cmh0105 • 4h ago
ᕕ(ᐛ)ᕗ My insurance keeps denying my RX for my allergic reaction due to lack of “medical necessity”
My insurance keeps denying my doctor’s prescription request because they require proof of medical necessity before approval. The pictures I’ve sent apparently don’t fit the bill of necessary medical needs 😅 (first picture is the day I broke out, second is a week later)
ETA: thanks for all the advice! I can’t keep up with the comments. I feel so dumb when it comes to insurance stuff so I’m relying heavily on my doctor. They have submitted another appeal so hopefully that goes through and I get the RX.
ETA2: y’all I did not expect this to blow up, I was just very annoyed that the insurance I pay for says I can’t have a medication that my doctor says I need without jumping through a million hoops. The folks telling me I am not providing enough context need to chill…shouldn’t my doctor saying I need this medication after a few others didn’t do anything be enough?
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u/Quiet-Egg-4594 4h ago
Insurer: meh, must be make up
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u/cmh0105 4h ago
They must think I’m a special effects artist or something
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u/scr33ner 3h ago
UH is known for using AI to handle claim eligibility. A human probably never even saw it.
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u/chickwithabrick 3h ago
Never forget: "A computer can never be held accountable, therefore a computer must never make a management decision." - IBM 1979
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u/BennyVsTheWorld 1h ago
When asked yesterday or the day before how he would hold AI accountable for crime, Trump responded that he changed the name and it’s now S.I. That was his entire response to the question.
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u/BugOperator 4h ago
Nah, they just figure if she can still walk and go to work and live normally from a physical standpoint, she’s fine. Who really needs a non-anaphylactic face? Claim denied.
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u/cmh0105 4h ago
Someone saw the pictures at UHC and said “looks good to me” 🫠
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u/Ok_Calligrapher5278 3h ago
Someone
"ChatGPT, is this person sick? Only answer with yes or no, if you say yes a puppy will die."
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u/MushroomComplete8484 4h ago
make an appeal, if they then make a final adverse determination, make an external appeal through the state. this usually makes insurance companies shit bricks and just cover your medication
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u/cmh0105 4h ago
Where would I go for the external appeal? I have never had my insurance deny this many times.
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u/Mira_DFalco 4h ago
The information on how to do that is required to be included on your denial letter.
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u/cmh0105 4h ago
Oh I gotcha, I haven’t gotten that yet but I got the call that “you’ll be getting a letter”
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u/Mira_DFalco 3h ago
The letter will also tell you why it denied, and should explain what their preferred options are. Your doctor can then 'splain why those won't work.
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u/UmCourt 2h ago
It's really sad when doctors are trying so hard to get us what we NEED and then this insurance person who most likely knows NOTHING about health is telling you that "no you dont need that".
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u/ElevatorOtis 3h ago
Has your doctor done the peer to peer? My neurosurgeon asks for the peer to peer when he gets pushback. Then, when he chats with the retired doctor that works for the insurance company, he asks, “Were you a neurosurgeon?” If they say no, then he replies, “I only do a peer to peer with another neurosurgeon and unless one is provided, then a peer to peer isn’t possible.” Insurance usually folds after that.
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u/Pertinent-nonsense 3h ago
I like your neurosurgeon.
Doubt he gets paid for all that fuckery he has to go through.
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u/Telefundo 3h ago
Doubt he gets paid for all that fuckery he has to go through.
Probably not. He's probably one of the few that has decided that if enough of them start to go through all that fuckery out of spite it might actually change something.
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u/MushroomComplete8484 4h ago
should be on the letter you've been given by the insurance company. if it isn't, mention it in the external appeal, as that's super illegal
as its an appeal to the state gov, it depends on what state you're in. if you search up "{your state} external appeal" it should appear. at least in new york it's through the department of financial services, though the department it's through varies state-by-state.→ More replies (1)→ More replies (13)33
u/SwoleJunkie1 3h ago
Google your states department of insurance. Call UHC to appeal their decision first and explain why it is medically necessary (ask your doctor for some ammo there), and if they don’t reverse it make the complaint to the DOI.
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u/Medical_Carrot_5318 3h ago
Ive literally had someone get denied for a surgery and made an appeal to have them still deny the procedure because said person needed a pregnancy test even those this person literally had on file that the previous surgery had made them 100% sterile. These insurance companies are an absolute joke
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u/Pilkie_ 2h ago edited 2h ago
I tore a bunch of ligaments, My doctor knew I tore ligaments. I had an x-ray done at the hospital, and the doctor needed an MRI to diagnose me. Insurance said I need an x-ray, my doctor told them I had an x-ray, insurance said they needed an x-ray from a specific x-ray. The place they needed me to go for the X-ray to be covered was like an hour and a half drive away, my doctor and I explained that I can't drive that long because of the ligament, tears and my doctor told them that an x-ray will not show any ligament damage and an MRI is needed.
Insurance asserted that they knew better than the doctor and that an x-ray was needed.
Imagine being a doctor, imagine spending 8 plus years slaving over textbooks and case reviews, working almost every waking hour of your life to achieve an acceptable semblance of mastery over medicine. Now. Imagine being that doctor, using all of his education to make a diagnosis or prescribe a treatment, then being told by some pencil pusher with no medical education at the insurance company that his diagnosis or treatment is wrong in their eyes.
Our system is fundamentally broken. All doctors, make an oath to "first do no harm". Insurance companies don't make such an oath, in fact, it is in their incentive to not follow that oath that is SO fundamental to practicing medicine. When I was a kid, I never understood the business model of insurance. Because when you think about it at its core, you pay tons of money to a company who will use that money to pay people whose job it is to find ways to not fulfill their end of the deal.
Something needs to change about how insurance is handled in this country.
EDIT: Fixed some grammar errors from my speech to text.
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u/JimmyJooish 4h ago
United health?
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u/cmh0105 4h ago
Yes 😩
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u/Cleasstra 4h ago
Swap asap if you can. They denied my grandmother's medically necessary treatments for an entire year after the luigi incident they became worse frankly.
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u/DrPuzzle 3h ago
They become worse after that? Jesus
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u/a_shootin_star WATWATWATWATWATWAT 2h ago
They have a never-ending supply of CEOs
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u/TheLoneCenturion95 4h ago
Does the US not have a higher authority to escalate this kind of stuff? Do the insurers truly get to chose if you live in pain or even if you get to live or die? Sorry if I'm ignorant but I'm British so the whole of American health care is appalling to me. A whole nation shouldn't have to suffer for greed.
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u/DigiTrailz 3h ago
Saidly yes, and these decisions arent even really often made by medical experts but people who just watches modules. Sometimes they arent even made by people now. The insurance can make up thier own rules.
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u/I-pee-Daily 3h ago
A lot of them are testing AI to see who gets denied and who lives.
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u/Dapper-Confection-84 3h ago
You can complain to the State agency that handles HMO’s and/or insurance companies. That said they will generally only get involved after you have appealed to your health plan and received a second denial. Include photos. This can change the outcome.
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u/Vortex_Analyst 3h ago
This, my father had to do that for his ..ready for it...his fucking insulin shot. Insane.
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u/soymilo_ 4h ago
I mean it's the same country where a University or College can apparently decide if a reported crime by student X should go to the police or not
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u/Constant-Plant-9378 3h ago
a University or College can apparently decide if a reported crime by student X should go to the police or not
It is never actually up to the school. The victim can go to their local police department and file a complaint. There is no law saying they have to use the school as a middle-man.
Same goes for assault in high school. Never make the mistake of feeling like you have to go through Admin.
When my daughter was assaulted on a band trip, and then Admin suspended her in response, I went straight to our local Police Chief. Turns out he had a lot to say about Admin at that school and he was happy to help. After filing the complaint, I emailed the school board and cc'd the Principal and Assistant Principal who had refused to address our concerns earlier that day.
The next morning I got a call asking for a meeting with the Principal and her Admin. We brought our daughter with us to the meeting so she could see us chew their ass. That was fun. Her suspension was overturned and they apologized to her. The band director was fired.
Admins in schools love to become petty dictators and pretend to be in law enforcement. They aren't. Just go to the police. It's amazing how quickly the bullshit stops once shit gets real.
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u/lost_rodditer 4h ago
Welcome the land of privatized medicine! Where you to can choose to pay rent or get 2 aspirin and a handshake for $2,000. Yes it's that bad. I have a full time job, medical insurance and the hospital still presumes I need financial assistance by default.
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u/RailRuler 3h ago
Yes, you can appeal the decision of the insurance company...to the appeals board of the insurance company that gets paid more if they deny more appeals.
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u/Historical_Air2790 4h ago
How is universal healthcare worse than this again? We all have stories of US insurance denying us personally or friends/family for BS reasons yet we HAVE to pay for it....
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u/hoppyending 4h ago edited 3h ago
My wife and I were bitching about veterinary costs last night and at some point she said, "How have the Americans been convinced that private healthcare is a good thing?"
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u/Ok_Concentrate4461 3h ago
Only the brainwashed cultists think it's a good thing. Every rational person knows it sucks but our country is run by corporations and billionaires.
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u/Floreat_democratia 4h ago
It isn’t and never was. It was revealed about a decade ago that the campaign against universal healthcare was a PR stunt funded by the health industry. There’s a book about it written by the person who ran the campaign and came clean.
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u/Temporary_Pickle_885 3h ago
Do you happen to know the name of the book? That'd go on my TBR so fast.
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u/MysticMarauder69 3h ago
Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans by Wendell Potter
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u/suctoes_N_fuchoes 3h ago
pay monthly insurance bill
get denied when you actually need to use it
Where tf all the money going?
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u/TheOfficeoholic 4h ago
1. Contact your states Department of Insurance or Insurance Commissioner. Call the hotline or file a formal inquiry or dispute.
2. If insurance is through work, ask for a healthcare advocate through your HR. They should be able to jump on a call and potentially help out also.
3. File an internal appeal: Submit a formal, evidence-backed dispute directly to your insurance carrier first.
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u/raincloudjoy 3h ago
to bullet 2- it is insane that we need to divulge (private) medical details to our employer (who often makes us pay for coverage) in order to receive basic care that a doctor, and their expertise, should ultimately determine
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u/Zexeos 3h ago
Call them and ask for the credentials of the doctor who is deciding that this isn’t necessary. Get their name and medical license number. When I owed $400 for anesthesia during an appendectomy (the fuck???) asking for the information suddenly made them change their tune, and they covered everything.
If they do give credentials and don’t change their minds, report that doctor to to medical board they report to for a breach of ethics and going against his oath.
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u/soymilo_ 4h ago
Shouldn't it be enough for the doctor to basically write "it's necessary". How would the insurance know what's necessary and what isn't? They aren't doctors, that's why you consult a doctor. The US is weird.
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u/notTheRealSU 4h ago
Simple. It's not medically necessary unless it kills you, and when it kills you it's not their problem anymore
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u/jws1102 3h ago
Remember when that CEO was shot? That same morning, Blue Cross Blue Shield announced that they would be letting cubicle goblins decide how much anesthesia was needed during surgery rather than the anesthesiologist.
They reversed that decision shortly after the shooting.
They don’t give a fuck about medical necessity, they’re business assholes and the only thing that matters to them is the bottom line. They care more about that than they will ever care about an actual human’s well being.
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u/Catdadesq 3h ago
Well see, they may not be medical experts, but they are very good at increasing shareholder value, which is obviously the primary purpose of a functional healthcare system.
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u/BalkanFerros 3h ago
The insurance company has a doctor they pay to say everything is unnecessary.
Deny Delay Depose
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u/Ok_Concentrate4461 3h ago
They just deny. My mom had a MASSIVE spinal epidural abscess and needed emergency spinal surgery. EVERYONE said it was a miracle she survived. The insurance company denied the surgery because they didn't try antibiotics first. One more day and she would have been dead. They eventually approved it, but it was a huge hassle for my stepdad to sort out, and for no good reason. They'd probably say OP should just try Benadryl.
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u/Ecstatic-Time-3838 3h ago
Our 13 month old son needed brain surgery to remove a tumor that was causing him to have seizures resulting in him not breathing for about 90 seconds at a time.
The insurance company (UH of course) fought the surgery up until the night before. Literally like 8pm at night and we were supposed to be at the hospital at like 6am the next morning for the surgery.
Our surgeon even called the insurance company pleading with them to let her do the surgery.
Insurance companies are a plight. The surgery went well and our son has made a pretty good recovery. His surgeon is an angel and we owe her everything for saving our son.
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u/cyrano_dvorak 3h ago
At this point, it is probably not even a person making the denial, it is probably AI or Super Stupid or whatever it is called these days.
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u/National_Moment_2037 4h ago
JFC! Is your doctor not helping here? They should get a peer-to-peer review with them.
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u/cmh0105 4h ago
They’ve appealed multiple times so now I’m waiting for next steps. I just want some relief from the itch and burn 🫠
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u/ClarkGablesTeeth 4h ago
UHC is relentless in their denials and stretching things out. They really are horrible.
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u/NJD1214 3h ago
I got denied my claim for a broken leg. They said it was not a medical emergency and I should have left to go to an in network hospital. The only reason they finally gave up and covered me was because the nurse in the ER wrote down that I asked about it, and she informed me I was in an emergent situation and couldn't leave the hospital. The total of the hospital bills for a day and a half with the surgery we're over 200k. Insanity.
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u/scripter86 3h ago
American Healthcare is a scam. In Germany, the cost would only be around $5,000. The deductible would probably be around $70.
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u/Equivalent-Metal9393 2h ago
The CEO really needs his 14 million bonus. Have you seen the price of groceries and Healthcare? He wouldn't be rolling in cash if he gave you your 10 dollars if medicine. Please, next time think about those poor millionaires before you post such mean things.
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u/monstersun 1h ago
Go to your local news im not even kiddding. The local news is your best way to tattle on big buisness for treating you like shit
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u/Blue1994a 4h ago
People here 🇬🇧 sometimes take it for granted living in a country with universal free healthcare. They shouldn’t.
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u/Medical_Carrot_5318 3h ago
Genuinely. Some people who get hurt and need an ambulance I have heard trying their hardest to refuse help or beg them to just end them right there because NO ONE wants those life long medical bills.. insurance is a scam.
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u/IanSaurX 3h ago edited 2h ago
Welcome to one of the richest countries in the world where your life altering illnesses can be "denied" by insurance companies, all for their own financial gain.
Edit: This seriously infuriates me to no end. My s/o has asthma along with an auto immune disease which is linked to it which we're still getting tests done to figure out what it is. She also works 12's as a CNA. She had to switch to night shift because her illness, since, when in the business of dayshift, it becomes debilitating to the point where all she can really do when she gets home is sleep, and wake up feeling like shit.
The doctors, as said, are still trying to figure out what's going on. This illness has popped up over and over since about 2 years ago, and I cannot exaggerate when I say that multiple doctors essentially told her its allergies, or some asthmatic response to something. Only NOW after all this time are they taking her seriously, realizing it's actually auto immune of some sort... but it doesn't end there, in this 1ST WORLD COUNTRY.
Tell me how a single fucking inhaler can be $800 without insurance?! You're telling me it costs that much to make? Cause it doesn't!! Just like insulin!! But here in America our insurance premiums are so outrageous that a healthcare worker with good insurance can still be raped by the system for something they NEED TO LIVE. She ended up getting approved for the $800 inhaler, thank God, but even still, how can we dare say that it's actually worth $800 whole dollars when, after insurance, its like ~$20?? What kind of fucking scam?
But wait, there's more to this 1ST WORLD circus!!
While our president is busy renaming AI to SI, and Lake Ontario to Lake America in order to divide and distract the public from our gov'ts overt corruption, insurance companies are holding people like my s/o under their gunpoint. Her treatment for what the specialists are thinking her disease is (which is a rare one), CAN be free for her - and I pray that it is - however, we are undergoing extensive and prolonged testing on her (which prolongs the time until she is actually treated), simply to make a case for the insurance company that she NEEDS the medicine. And as we see with OP, sometimes what should be a closed case for getting coverage, is shut down by the insurance companies for a multitude of bullshit reasons all to save pennies on the dollar.
What are we doing? Is this what soldiers fight and die for? Is this really where we are in 2026? We can give tax loopholes to billionaires but can't give affordable healthcare to those who really need it?
WHAT. IS. GOING. ON.
SOMETHING. MUST. CHANGE.
"We hungry but them belly full"
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u/Educational-Low-2401 4h ago
It’s self defeating. They deny coverage, client dies, they lose a paying client. Who wins?
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u/TheVeil36 3h ago
Insurance is a scam 90% of the time and just a way to launder money directly from you and businesses into polical hands. I'm sure people will disagree. Heck, my own sister is a perfect example of why I surnace exists. But I ask why are me and my wife paying 12k a year, plus have a $5k stop loss and then my insurance can't decide they don't want to cover something or say my DR is wrong and deny my claim. They are a for profit business, they should not be allowed to overrule DR findings . There's a reason you can't sue insurance companies and our polical system in the states approved it
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u/Whiterabbit-- 2h ago
It’s crazy that insurance can dictate what is needed as opposed to doctors. There should be legislation that doctors determine medical necessity, not insurance companies. If insurance is to deny coverage it can’t be based on medical necessity. That is not their determination.
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u/NocturneSapphire 2h ago
I SURE DO LOVE HAVING 20% OF MY PAYCHECK DEDUCTED TO PAY FOR HEALTH INSURANCE THAT DOESN'T EVEN COVER MY MEDICAL NEEDS! THAT'S SUCH A BETTER SYSTEM THAN HAVING 2% DEDUCTED IN TAXES TO ACTUALLY COVER ALL MY MEDICAL NEEDS! I CAN'T WAIT TO VOTE AGAINST CANDIDATES WHO SUPPORT UNIVERSAL HEALTHCARE BECAUSE THEY'RE DIRTY SOCIALISTS ACCORDING TO THE LOUD MAN IN MY TV!!
- American voters, consistently
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u/jws1102 3h ago edited 3h ago
Health insurance shouldn’t even be a thing.
You have insurance in case something happens, like if you happen to get in a wreck or have a house fire.
Health problems are going to happen to everyone that’s lucky enough to make it beyond middle age. We shouldn’t need insurance for things that are certain.
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u/Axe_Care_By_Eugene 2h ago
You have to wonder how the people denying the absolutely necessary treatment, sleep at night. Scum of the earth.
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u/FoxxyPantz 1h ago
If medical insurance never existed and someone said "what if the doctor had to ask a company, primarily made of non-doctors for approval of a medication for their patient?" We would all agree that's the dumbest fucking thing someone could think of
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u/SunnyTheMasterSwitch 4h ago
Insurace companies being able to decide whether you can afford medication.... what a dystopian concept...
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u/notypants 3h ago
Used to be the person submitting Rx prior auths for a clinic of 40 providers. I did it for ten years. I’m now a tattoo artist.
Fuck. These. Insurance. Companies.
They aren’t your friend. They aren’t our friend. They are a business and they do not care if people die because of their shitass business.
All that is to say: we at the doctors’ offices see this happening all the time and we hate it too.
I’m so sorry OP. 🖤
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u/theNixher 3h ago
Greatest country in the world.
Meanwhile, in the UK, you'll likely get this from a pharmacy, if not next day appointment with a £9.50 prescription charge.
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u/OutrageousCrab9224 3h ago
I am sorry
American healthcare exists to feed capitalism, not help humans
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u/Traditional_Map2192 3h ago
So... there was a 21-year-old (if I remember correctly) with severe asthma whose insurance company, rather than accept the word of an actual doctor, refused his prescription because they felt he should try less extreme methods of aiding his asthma first.
They made him choose between affording his medication, and keeping a roof over his head.
He chose to keep a roof over his head that month.
He died of an extreme asthma attack, bevause he did not have a helpful medication, because an unqualified insurance agent with no medical experience decided to ignore the advice of a licensed physician and refuse to cover a life-saving medication.
And this happens every freaking day.
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u/Danny_Mc_71 3h ago
What exactly is the medication?
Like would someone from a normal country be able to buy some and post it to you, if they were so inclined?
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u/Kind_Of_A_Dick 3h ago
Why isn’t the doctor’s request considered enough to make it medically necessary?
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u/1738_bestgirl 1h ago
I feel so dumb when it comes to insurance stuff so I’m relying heavily on my doctor
Hey OP just want to point out this isn't on you. US health insurance is purposefully convoluted to deny care to patients.
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u/Misubi_Bluth 3h ago
Dude these leeches would try to argue chemo isn't medically necessary. They can pound sand.
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u/ChartreuseOblivion 2h ago
1) Get the prescription from your doctor...
2) Go to the pharmacy that participates in "GoodRx"...
3) Tell them you have no insurance and to please use GoodRx...
4) You get the GoodRx price (up to 80% off many prescriptions!)
5) PROFIT!!
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u/mrbasedballed 1h ago
Health insurance has just become parasitic and it does the opposite of keeping people healthy. Why the fuck are we still putting up with this? I swear I live in the most pathetic country.
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u/izmebtw 3h ago
That’s so weird. In Canada if your doctor writes it they give it.
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u/Daetok_Lochannis 3h ago
In America your doctor has to prove to the insurance company that the treatment is necessary, and even if it's necessary it has to fall within the guidelines of the treatments you've paid to have covered in a hospital your insurance company has agreed to pay.
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u/navetzz 2h ago
My insurance keeps denying my doctor’s prescription request because they require proof of medical necessity
In what fucked up universe is a doctor's prescription not a proof of medical necessity...
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u/JustWowinCA 4h ago
I'd go to their website and post your pictures, then go to X 'at the company' and post the photos and link them. I'm sorry to say but public shaming seems to be the only thing working today.
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u/Saruvan_the_White 3h ago
For every denied claim like this, those who deny the claim should be forced to endure the same medical condition for lack of care. In fact, we should invent ways to foist medical conditions upon health insurance execs and the people who deny these claims.
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u/MissPanthyr 3h ago edited 1h ago
Contact the Bureau of Insurance in your state and start from there. If it goes to arbitration the insurance usually has to pay for that and depending on costs it may be cheaper to just pay claims that they may be forced to pay anyhow rather than go through the whole process.
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u/bmxracers 3h ago
You can’t establish medical need, that’s on your doctor. Get the office involved. It’s extra steps, but persistence will pay off.
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u/TheTrombiculidae 2h ago
I donotunderstand how insurance companies are allowed to get away with practicing medicine without a license
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u/Acrobatic-Narwhal644 2h ago
My insurance denied my medication and I told them I was calling a lawyer. I had pics of my condition. Got my approval real quick. I was going for a legal consult if I was denied again.
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u/Bender_2024 2h ago
Medical necessity really shouldn't be "unless you are going to die without it"
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u/Formal_Plum_2285 3h ago
To think there are people, who’ll do anything to start a life in the US, really shows their level of desperation.
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u/pixiegrl2466 3h ago
Sometimes the Good Rx price is cheaper than using my insurance at CVS. Might try it.
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u/Penguin_shit15 1h ago
Hey there.. I am in Hospital Administration and any time you have any kind of questions, feel free to hit me up. Not saying that I know more than some of the people in the post.. but I have done this stuff for 20 years.
Hit me up in an DM anytime.
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u/xKriegx96 1h ago
I don't agree with or condone murders or assassinations, but this is part of the reason people like the United healthcare ceo was shot and killed.
You pay hundreds of dollars every month, and some people like my uncle spend $200 every week for coverage. The health insurance companies say they reserve the right the deny coverage.
Absolute insanity.
Seeing stuff like this makes me want to go to finland or somewhere that's not here lol
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u/Ange1ofD4rkness 3h ago
Your doctor should be having this fight for you.
My insurance tries to deny one my medications, saying I can take the generic instead. However, the generic is not as effective. so my doctor simply sends them an appeal pretty much saying "no, you need to fill the name brand".
Insurance companies like to make it difficult, hoping people just give up.
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u/JazzlikeSchedule2901 3h ago
The fact its so close to the eyes is scary. That is an insane thing to deny when its clear treatment is necessary..
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u/Welsh_Dodo 3h ago
Guessing you're in the USA where healthcare is for profit only. Sorry to hear that
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u/sanlill GREEN 4h ago
name and shame the insurance company.