The first-line of decision making about a health plan’s coverage is typically made by a utilization review manager/case manager. If your provider prescribes you a service for DM, this utilization review manager will conduct a utilization review before your insurance company can approve coverage. According to the American Physical Therapy Association (APTA), a utilization review is the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, medications, and durable medical equipment under the provisions of your applicable health benefits plan.

Unfortunately, many individuals living with DM are often denied coverage for services because a utilization review manager will deem the services to be medically unnecessary. These decision makers may have no expertise in the complex, multisystemic needs of a person living with DM. They are also likely to be unfamiliar with DM since it is a rare disease. Utilization review managers can reject claims outright or approve claims for part of the recommended diagnosis or symptom management plan. This is a common experience within the DM community.

Coverage denial can be especially frustrating because individuals with well-known diseases have a higher likelihood of coverage for services than someone with DM might have, even with the same insurance plan and the same symptoms. For example, one DM community member expressed their concern about a situation where their provider claimed they had narcolepsy instead of DM in order to get coverage for the drug Modafinil (Provigil), which helps individuals manage excessive daytime sleepiness. Since narcolepsy is an easily-diagnosed, well-known disorder, a utilization review manager found Modafinil to be a medically necessary service for managing narcolepsy symptoms. However, since DM is a rare disease, a utilization review manager may be hesitant to cover the Modafinil prescription because of their unfamiliarity with DM and its manifestations.

This DM community member, as well as many others, have expressed their concern that utilization review managers and insurance companies are often not aware of the symptom management strategies that are medically necessary for people living with DM. Adverse utilization management decisions may deny access to care that a healthcare provider determined to be medically necessary. For this reason, it’s critical that utilization review managers are at least as qualified as the doctors and specialists prescribing the drugs or medical services to the DM consumer.

Read the following from the National Library of Medicine about the utilization review process.

• Pre-certification Review: Conducted at the onset of a service or treatment. This review is performed before care is rendered in order to eliminate or reduce unnecessary services.
• Concurrent Review: Performed during the course of the diagnosis or symptom management process of care. Intervention occurs at various intervals and may encompass case management activities such as care coordination and care transitioning. Concurrent review may have the impact of curtailing an existing episode of care.
• Retrospective Review: Conducted after the service has been completed and assesses the appropriateness of the procedure, setting, and timing in accordance with specified criteria. Such reviews often relate to payment and result in denial of a claim. Financial risk for a retrospective denial is often, but not always, borne by the provider.
• If you are denied coverage after the utilization review process occurs, you are encouraged to appeal your insurance company’s decision if you and your provider deem the rejected services to be medically necessary.