Nevada Radiofrequency Ablation (RFA) Insurance Denial
Chronic pain is not just a physical problem. A study based on self-reported data collected by Mental Health America found that “people living with chronic pain are at heightened risk for mental health problems, including depression, anxiety, and substance use disorders.”
Finding safe, effective treatments to alleviate pain can improve both a patient’s physical health as well as their mental and emotional well-being. As health care and technology have advanced, so too have treatment options for patients living with chronic pain.
Insurance companies haven’t advanced their profit-boosting tactics, though. Instead, they continue to regularly engage in bad faith practices, including denying what are otherwise valid claims.
If you’re dealing with a Nevada radiofrequency ablation (RFA) insurance denial, we want to speak with you. As a law firm founded on the principle of helping those who have been wronged by others, we are committed to providing unparalleled legal guidance on even the most complex insurance denial claims.
You can learn more about our services during your completely free case evaluation.
Therapeutic Uses for Radiofrequency Ablation
Radiofrequency ablation (RFA) is a medical procedure used for both nerve ablation and treating venous insufficiency.
In nerve ablation, radio waves are used to treat chronic pain, especially in the lower back, neck, and in arthritic joints. This treatment is generally only considered for patients who haven’t found relief with other treatment options, such as corticosteroids, muscle relaxers, and anticonvulsants.
RFA is administered by placing a needle in the affected area, through which a current of radio waves is used to heat the nerve tissue. This process effectively destroys the nerve, which prevents it from sending any pain signals to the brain. Approximately 70% of patients who undergo RFA experience pain relief for a period of at least one year.
When treating chronic venous insufficiency, RFA uses radio waves to seal off diseased veins in the legs. This redirects blood flow to healthy veins, preventing blood from pooling in the lower extremities and improving overall blood flow to the heart.
Doctors sometimes also use RFA to treat abnormal heartbeats, non-cancerous thyroid nodules, varicose veins, and to shrink tumors.
Side Effects of RFA
RFA is generally considered to be a safer alternative to other medical procedures for chronic pain, such as open surgery. However, no treatment option is without risk. The main side effects and risks of RFA are:
- Bleeding at the site where the probe was inserted
- Weakness or numbness at the insertion site
- Swelling or bruising
- Permanent change of voice
Even though the possibility of suffering any of the above side effects is low, every patient must be informed of the risks and benefits through a process known as informed consent.
Is Radiofrequency Ablation Covered by Health Insurance?
Many private health insurance providers, including Medicare and Medicaid, cover radiofrequency ablation as a treatment for specific conditions. However, policyholders generally must meet certain criteria before insurers are willing to pay for RFA treatment.
For example, Medicare only covers RFA for chronic pain under the following conditions:
- Chronic pain has been present for a period of at least three months and has been unresponsive to other forms of pain management.
- The pain is moderate or severe, resulting in a functional deficit during daily life.
- The pain is not caused by an infection, fracture, deformity, or tumor.
If you have coverage through a private insurer, such as UnitedHealth Group, Aetna, Anthem, Blue Cross Blue Shield, Humana, or Cigna, requirements for RFA treatment may be different.
An experienced attorney from the Law Office of Matthew L. Sharp can help you determine whether this treatment is covered by your insurer during a free consultation. We’ll also cover your legal options if your insurance company denied coverage for radiofrequency ablation when it should have been covered.
Why Insurers Deny Claims for Radiofrequency Ablation
Health insurance companies deny claims for a variety of reasons, citing everything from exclusion of service (not covered by the policy) to failure to secure preauthorization. However, these are not always valid reasons. Instead, they are often the insurer’s excuse for denying your claim in an effort to save money.
Health insurance companies shouldn’t be in charge of who gets treatment and who doesn’t. If you’ve experienced a Nevada radiofrequency ablation (RFA) insurance denial, you have legal options to ensure your insurance provider properly covers the treatments and procedures that you need to live a healthy, fulfilling life.
That’s why at the Law Office of Matthew L. Sharp, we’re well-versed in the four categories that denials fall into most frequently. Let’s review those categories now.
Treatment Is Not Medically Necessary
Insurance claims aren’t handled by teams of medical professionals with specialized knowledge. Instead, when a claim is submitted to your health insurance, it is handled by a claims adjuster.
And never forget—the claims adjuster works for the health insurance company, not for you.
It is their role to preserve the profits and viability of their employer. Denying claims that they don’t believe to be medically necessary is all part of their job.
These decisions are rarely rooted in medical knowledge, though. What your doctor or specialist knows to be a medically necessary (or even life-saving) medical procedure might just look like a big and unnecessary expense to the adjuster handling your claim.
If your radiofrequency ablation claim was denied because of a lack of medical necessity, but you need pain relief now, you need the guidance and backing of a knowledgeable attorney who isn’t afraid to stand up for what is right. Schedule your first free consultation with our Nevada law office to learn more.
Treatment Is Experimental or Investigational
Health insurance companies rarely (if ever) approve claims that they believe to be experimental or investigational. An experimental or investigational treatment is one that has yet to be approved for the treatment of an illness, injury, disease, or condition that is not recognized as a standard medical treatment for a specific diagnosis.
In other words, health insurers don’t want to pay for treatments unless they are absolutely certain that it will work.
Most insurers will not pay for off-label use of a prescription drug or treatment, even when there is data or evidence that supports a doctor’s decision to prescribe it.
Securing coverage for a treatment that was denied for being investigational or experimental is not impossible, though. A Nevada radiofrequency insurance denial lawyer from the Law Office of Matthew L. Sharp can help.
Policy Benefit Limit Has Been Reached
A benefit limit is the “maximum amount of money that an insurance company…will pay for claims within a specific time period.” While less common than they used to be, many plans still have benefit limits that impose a manufactured cap on how much an insurer is willing to pay for your care in a specified period of time.
The passage of the 2010 Affordable Care Act (ACA) prohibited health insurers from setting blanket annual or lifetime benefit limits for all care on insurance policies, although there are two notable exceptions:
- Plans or policies that have been grandfathered in
- Health care services that aren’t considered to be essential
This means that if you have a grandfathered plan or some of your care has been labeled as non-essential, your insurer could deny payments for additional services it considers non-essential for your condition.
If the insurance company claims that you’ve reached your benefit limit and refuses to pay for your RFA treatment, contact the Law Office of Matthew L. Sharp as soon as possible. Miscalculations, double billing, and erroneous coding can all falsely inflate the cost of medical care.
An attorney can evaluate your medical records and billing history to determine whether your insurer may have overpaid for your care, resulting in a false determination that you’ve reached your benefit limit for the year.
Although reforms introduced through the ACA were supposed to expand access to in-network care, many health insurance providers began narrowing their networks as early as 2015.
Narrow or inadequate networks leave policyholders with few options for seeking medical care, often limiting them to just a handful of doctors, specialists, and hospitals that are deemed in-network. And if there are no in-network doctors that perform radiofrequency ablation, the insurance company is under no obligation to cover the procedure.
This might not be wholly legal, though. An insurance company that purposely excludes providers needed for essential care is typically engaging in bad faith insurance practices, and may even be in violation of federal law.
Under the ACA, the U.S. Department of Health and Human Services (HHS) requires that all health insurers provide a sufficient number of in-network providers, including essential community providers (ECP) for low-income communities and individuals who are medically underserved.
Speak with a bad faith insurance attorney today if you’ve been told that your procedure isn’t covered due to a lack of in-network providers.
Dealing With a Nevada Radiofrequency Ablation (RFA) Insurance Denial? We Can Help
At the Law Office of Matthew L. Sharp, we know that insurance companies rarely play fair. If your claim for radiofrequency ablation was denied, but you need help with your chronic pain now, please contact our law office as soon as possible.
We’ll schedule you for a free case evaluation with a bad faith insurance lawyer who will go over the details of your claim, what your policy covers, and your legal options to hold the insurance company accountable.
“I recently retained the professional services of Matthew Sharp and his law firm to represent my interest in a legal proceeding. Mr. Sharp and his firm shall I say was way over the top in providing excellent and sound legal advice. His professional attitude and attention to detail during the entire process was second to none as well as the rapid and courteous responses from Mr. Sharp and his staff to any and all of my questions regarding my case. Furthermore, I would give my utmost support to anyone choosing Mr. Sharp and his firm in any type of legal representation.”
- RICK S.