reading prior authorization threads from 2024 and half of it aged badly
reading prior authorization threads from 2024 and half of it aged badly, which sounds obvious until you try to state the evidence for it.
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.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
Not medical advice, obviously, and nothing here is approved for human use. One person with a spreadsheet.
best — the order this archive was captured in
Member and policy numbers redacted from the screenshot above. Everything else left as posted.
Member and policy numbers redacted from the screenshot above.
This is the whole method. Answer the criterion they named, not the decision in general.
deadlines run from the letter date, not from when you opened it
External review, which is the most underused mechanism discussed on this board.
Internal appeals are decided by the plan. External review sends the determination to an independent body. Where it applies its decision binds the plan, and the deadlines to request it are short and strictly enforced.
The two things that trip people up: not knowing it exists, and exhausting the internal levels so slowly that the external window closes. Ask on the first denial what the external route is and what the deadline will be. Availability and rules vary by jurisdiction and plan type, so say where you are when you ask here.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
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.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
Careful — the deadline runs from the date on the letter. Waiting for a call back can cost you the appeal entirely.
That criterion is from the previous plan year. The current bulletin has different wording.
the formulary is published, read it before you appeal
Has a peer-to-peer been offered or requested?
Small fix — external review is independent of the plan. The second-level internal appeal is not.
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.
Agreed. The denial letter tells you which criterion failed, and answering that specific criterion is the entire job.
document what has been tried and for how long, that is the whole case
Have you asked for the clinical policy bulletin by number?
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
the diagnosis code on the claim is doing more work than anything you write
the diagnosis code on the claim is doing more work than anything you write
runa_wikstrom is right that this is documentation rather than persuasion. It took me a year to accept that.
a template letter that quotes their own criteria back is the strongest one
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
Cosigning on external review. It is a real mechanism, it is underused, and the deadlines are strict.
What exactly does the denial letter give as the reason?
appeal in writing even when they say a call is enough
Which country and which plan year are we talking about?
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.
- 1External review, which is the most underused mechanism discussed on this…12 comments in this branch · started by u/muscle_cramp_mo
- 2Agreed on the plan-year point. Criteria that applied last year may simply…9 comments in this branch · started by u/liv_vukovic