three years of appeal threads, summarised so you do not have to read them
three years of appeal threads, summarised so you do not have to read them. I have gone back and forth on this for months.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
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.
Asked for the policy bulletin by number and wrote the appeal against its criteria line by line. Approved on the second level after a flat first-level denial.
Research-use-only material is not approved for human use and nothing here should be read as a recommendation to use it.
best — the order this archive was captured in
Internal appeals are decided by the plan. External review is decided by an independent body and, where it applies, its determination is binding. They are separate mechanisms and the second is chronically underused.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
That advice is jurisdiction-specific and this board spans several. Say where you are.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
deadlines run from the letter date, not from when you opened it
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
the second-level appeal is where things actually turn
Has a peer-to-peer been offered or requested?
Same view. The second-level appeal is where mine turned, after a first-level denial that looked final.
Same view.
This is the whole method. Answer the criterion they named, not the decision in general.
What exactly does the denial letter give as the reason?
External review was the thing that finally worked. I did not know it existed until a thread on this board.
What has been documented as tried, and for how long?
the diagnosis code on the claim is doing more work than anything you write
external review exists and almost nobody uses it
prior authorisation criteria change every plan year
appeal in writing even when they say a call is enough
Small fix — external review is independent of the plan. The second-level internal appeal is not.
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
Small fix — external review is independent of the plan.
Agreed — and request the bulletin by number. They have to give it to you.
a peer-to-peer call is often faster than a written appeal
Not convinced. That is a formulary exclusion rather than a prior authorisation denial, and the route to challenge it is different.
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
ask for the denial reason in writing, always
a peer-to-peer call is often faster than a written appeal
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
That criterion is from the previous plan year. The current bulletin has different wording.
the formulary is published, read it before you appeal
Correcting myself upthread: the deadline was 3 days, not the figure I gave.
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.
- 1Internal appeals are decided by the plan. External review is decided by an…16 comments in this branch · started by u/greta_chukwu
- 2appeal in writing even when they say a call is enough11 comments in this branch · started by u/line_bergstrom