c/insurancefights · created 1 Dec 2023
Prior auth, denials, appeals, formulary exclusions. Templates inside.
US, employer plan, eleven months start to finish. The thing that finally worked was embarrassingly simple. Denials one through three were all "not medically necessary"…
four denials, three appeals, one external review, approved, which sounds obvious until you try to state the evidence for it. A denial letter is required to state a…
reason code says "not medically necessary" at BMI 38. sure. Making the case below, and I expect to lose some of it in the comments. Documented eighteen months of what…
step therapy — how do i document failing something cheaper. I would rather ask a basic question now than get this wrong quietly for two months. Asked for the policy…
Reference standards, analytical reagents and system-suitability material. If you are running your own method, start with a known.
Reference standardsthe external review process nobody tells you exists. Short post, long comment section, probably. New plan year, entirely new criteria, and the denial that had been…
employer carve-out was in the plan document, not the summary. I have gone back and forth on this for months. Internal appeals are decided by the plan. External review…
The title is the argument: approved after i sent them their own policy criteria back. Here is the rest of it. A denial letter is required to state a reason and to…
does the copay card stack with anything or is that a myth — that is what I am asking, and I have already read the wiki twice. External review, which is the most…
denial reason codes decoded, mostly fixable paperwork. Making the case below, and I expect to lose some of it in the comments. Documented eighteen months of what had…
HSA dollars changed the real cost by a third and i nearly missed it. I have gone back and forth on this for months. Internal appeals are decided by the plan. External…
peer-to-peer review: what to say and what to bring. Short post, long comment section, probably. New plan year, entirely new criteria, and the denial that had been…
help me understand denial, I have read the wiki twice. I would rather ask a basic question now than get this wrong quietly for two months. Asked for the policy bulletin…
The title is the argument: unpopular opinion: most of what gets said here about step therapy is guesswork. Here is the rest of it. New plan year, entirely new criteria,…
step therapy is doing more work than we give it credit for. Not a hot take, just something I have not seen said plainly here. Step therapy requires documented trial of…
Putting this at the top of the board where it belongs: external review is not what most of this community thinks it is. Internal appeals are decided by the plan.…
Send the vial, get the number. Third-party purity and identity testing, results published to you regardless of what they say.
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glbiochem.netThe title is the whole question — does appeal actually matter or is it forum lore at this point — but here is why I am asking. A denial letter is required to state a…
unpopular opinion: most of what gets said here about formulary is guesswork. Not a hot take, just something I have not seen said plainly here. Step therapy requires…
how much of what we believe about copay actually comes from appeal threads. Searched first, found three threads that contradict each other, hence the post. Asked for…
The title is the argument: three years of prior authorization threads, summarised so you do not have to read them. Here is the rest of it. Prior authorisation criteria…
the denial question that gets asked weekly, answered properly, and I am aware this is a minority view on this board. The process that has actually worked for people on…
Question in the title, detail here: help me understand step therapy, I have read the wiki twice. New plan year, entirely new criteria, and the denial that had been…
The title is the whole question — can we stop arguing about copay until somebody posts a number — but here is why I am asking. Prior authorisation criteria are…
prior authorization — 22 things I got wrong before I got it right, and I am aware this is a minority view on this board. Kept a log with every date, name of department…
appeal is the most under-discussed thing on this board — a position I have arrived at slowly and would like tested. Employer-sponsored plans may be regulated…
the UK — has anyone got a straight answer on formulary, and I want the answer with the reasoning attached rather than just the conclusion. Kept a log with every date,…
The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.
Independent testing plus vendor-level trend data. Community-funded, unaffiliated.
peptidemeter.comSeveral compounds discussed on GLP Research Hub are sold for research use only and are not approved for human use anywhere. Nothing here is medical advice and none of it is written by your clinician. If a post reads like an instruction, treat it as a description of what one stranger did.
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