[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…
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.