If your insurance company turns you down for a procedure that has been approved by the FDA, what r options?

I have been rejected twice by my insurance company to have a vns implant implanted for treatment resistant depression. The treatment is FDA approved for treatment resistant depression, but the insurance company claims their reason is that the procedure is still experimental, even though it has been approved since 2005.
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Please do not answer with things like the fda doesn't govern the insurance companies. I want an answer that tells me what I can do in this situation, where to take things from here, who to contact, what I can do to change my insurance companies decision, besides writing a personal letter to them.

The only thing you really can do is write an appeal letter. (Unless you want to take them to court, but you'll still have to appeal first. Any judge is going to want to see evidence that you used your appeal rights and were denied each time by the insurer.)

It typically takes a pretty long time from the point where a procedure receives FDA approval to the point where it is covered by insurance. The FDA makes their determination based on whether a procedure is safe.

However, insurance companies (including Medicare) have to consider more than just whether its safe...they also have to consider whether the treatment is more effective than the other alternatives on the market, whether the procedure is cost effective, etc. It takes quite some time...in some cases, several years...for enough data to be available on the cost-effectiveness of a newly approved treatment and also to compare its effectiveness to other alternatives.

Quite often, Medicare is the first to decide to cover a procedure, then other insurers follow suit. If Medicare considers a procedure experimental/investigational, then you can be fairly certain that no other insurance company will cover it either.

So...if you're going to submit an effective appeal letter, I'd recommend including documentation about other insurance companies that are currently providing coverage, clinical documentation from medical journals (your doctor may be able to help you with this), etc.

(No insurance company wants to be the "first" to decide to cover a new, expensive procedure. However, they don't really want to be the "last" either.) ;)

I was going to list some insurance companies who do cover that treatment for you, to get you started on your appeal letter. Unfortunately, none of the large national insurers that I was able to look up online seem to cover it. Sorry. (I did find one insurance company that does...here's the link to their policy on it: http://provider.medmutual.com/TOOLS_and_RESOURCES/Care_Management/MedPolicies/PDF/200611.pdf#xml=http://dmzsearch.antaressolutions.com/texis/search/pdfhi.txt?query=vagus+depression&pr=MedPolicies&prox=page&rorder=500&rprox=500&rdfreq=500&rwfreq=500&rlead=500&sufs=0&order=r&cq=&id=48cc5c4067 )

Try to get your doctor to fight the insurance company for you. Mine had to do that when my insurance company denied Lupron (which has been on the market for 10 years). Sometimes you just need a doctor to prove to them that you really need it.

The issue is not FDA approval - the issue is what your policy covers and excludes.

It doesn't matter what the FDA has approved. They do not govern the insurance company's contract. Sorry.

You can appeal it - call member services and ask how - but you can't force an insurance company to pay for something it doesn't cover. Get your doctors involved with the appeal - they can provide documentation of medical necessity.

The state Department of Insurance of your state.

Also, the FDA does not approve procedures. The FDA approved the thing that you want to have implanted (the device and/or the medicine), but not the implantation procedure (what the doctor does).

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