[Win] four denials, three appeals, one external review, approved
Something I noticed reading old threads that I have not seen said out loud.
The advice on external review in this community changed substantially around the start of last year, and nobody went back and updated the older posts. So depending on which thread the search engine hands you, you get two contradictory answers with the same confidence.
I have listed what I think the current consensus is below. Correct me — that is the point of posting it.
best — the order this archive was captured in
Yeah, the denial code matters, it tells you what to fight.
Not to be pedantic but formulary and appeal are being used interchangeably and they are not interchangeable in real life.
The confident tone is doing a lot of work that the evidence is not.
Did you get step therapy or outright denial?
step therapy documentation is the weapon, use it
Three years on this site and the questions have not changed at all. Which is depressing or reassuring depending on the day.
I am going to push back on this slightly.
formulary exclusions are negotiable sometimes
formulary exclusions are negotiable sometimes
Yes, exactly this, and it is the bit that took me 84 weeks to accept.
Copay was external review for the copay then another 16% of the total. Read the actual plan document.
the carve-out clause varies by employer
do not suggest misrepresenting a diagnosis, that is fraud
- 1it is in the wiki actually6 comments in this branch · started by u/ferritin_low
- 2formulary exclusions are negotiable sometimes4 comments in this branch · started by u/adaeze_weiss