HOME » Denied Healthcare Claim Overturned Case Study

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This claim was denied because the patient had already proceeded through a long course of fertility services, and that course of treatment had already exhausted the full extent of fertility benefits in the patient’s policy. The hospital’s notes indicated that this claim did consist of continuing treatment in that same course of fertility services.

After verifying the above information with Humana, the patient’s health insurer, Convergent obtained claim documentation and medical record information to review the specific circumstances of the services that were rendered. In the course of this review, it was noted that the patient suffered from endometriosis concurrently with (and as a likely cause of) the infertility diagnosis. While the services were performed to address infertility, review of the matter indicated that a separate medical basis could have existed to provide the same services purely for the diagnosis of endometriosis.

In light of this, Convergent submitted an appeal contending that regardless of the prior history of fertility treatment (which was clear and undisputed), this particular instance of treatment was supported by medical factors other than fertility alone. After review of this appeal, Humana overturned the denial and issued payment in the amount of $25,296.11, the full contract rate due.