[Denied] reason code says "not medically necessary" at BMI 38. sure.
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 had been tried in a one-page table. That table was the appeal.
External review was the thing that finally worked. I did not know it existed until a thread on this board.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
Screenshot none of this. Read the whole thread, including the parts where I am told I am wrong.
best — the order this archive was captured in
Prior authorisation criteria are republished each plan year. A criterion that blocked you in one year may not exist in the next, so a denial is worth retesting after the turnover.
Same view. The second-level appeal is where mine turned, after a first-level denial that looked final.
the formulary is published, read it before you appeal
Step therapy requires documented trial of preferred alternatives. It is not an argument to be won on merits; it is a record to be produced, and the record is what the appeal must contain.
Left up. It carries dates, a criterion and an outcome, which is what makes these threads useful.
A denial letter is required to state a reason and to reference the criterion applied. That reference is the handle: request the clinical policy document by its identifier and answer it point by point.
A denial letter is required to state a reason and to reference the criterion applied.
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
Correcting myself upthread: the deadline was 23 days, not the figure I gave.
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
I would not skip the peer-to-peer.
oskar_kaufmann is right that this is documentation rather than persuasion. It took me a year to accept that.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
- 1Left up. It carries dates, a criterion and an outcome, which is what makes…7 comments in this branch · started by u/prior_auth_pain