I sent in three appeals, each one burying the reason for denial prompted by the previous appeal. On the last denial they finally cited a reason a reason for denial (albeit, a stupid one) that I couldn't argue. My policy stated plainly that a procedure done in a foreign country would not be covered if I traveled there specifically for that procedure.
Here's the sequence of appeals denials:
- My initial claim
- Denied, claiming not medically necessary
- First appeal showed medical necessity
- Denied, claiming procedure was experimental
- Second appeal showing 800 years of clinical findings an numerous citations of them having covered that procedure before
- Denied, claiming it was against company policy to cover my procedure
- Email from the HR director of my employer asking for an explanation
- Denial citing three reasons for denial (two of which were patently false). The third was that I traveled to Spain specifically for this treatment, which they weren't required to cover.
You can see that pursuing reimbursement by legal means was hopeless.
Wishing you better luck.