My biologic infusion was denied because of site of care. What can I do?
A site-of-care denial means the plan may cover the drug but refuses the hospital outpatient or office infusion location, usually pushing home infusion or a standalone center. Appeal by showing why the ordered site is medically necessary for this patient, or ask for reprocessing at an approved infusion site if location is the only issue.
What to do, in order
- Step 1
Confirm whether the drug itself is approved
Do not fight a site-of-care denial as if the drug were non-formulary. Ask whether the medication is approved if given elsewhere.
- Step 2
Get the site-of-care policy
Plans often list medical exceptions: prior reaction, unstable condition, complex monitoring, pediatric needs, access issues, or failed home infusion.
- Step 3
Document why the requested site is needed
Prior infusion reactions, comorbidities, difficult IV access, monitoring needs, or medication handling can justify the site.
- Step 4
If safe, consider an approved site
If the patient can safely use a lower-cost site, ask for a quick transfer so treatment is not delayed while the appeal continues.
The deadline that applies
At least 180 days to appeal on employer and ACA plans. If a delayed infusion risks flare, hospitalization, or serious deterioration, ask for expedited review.
Calculate your date →Documents to gather
- Site-of-care denial
- Drug approval or PA letter
- Infusion history
- Prior reaction or monitoring records
- Specialist statement
Go deeper
Related questions
Does site of care mean the drug is denied?
Not necessarily. The plan may be saying the drug is covered only at a different infusion site.
Can convenience justify hospital outpatient infusion?
Usually no. The appeal needs medical need, safety, access, or monitoring reasons.
What if the plan's approved site has no appointments?
Document the wait times and ask for a network-gap or continuity exception.
Sources
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