[Win] four denials, three appeals, one external review, approved
US, employer plan, eleven months start to finish. The thing that finally worked was embarrassingly simple.
Denials one through three were all "not medically necessary" with no further detail. Appeals one and two restated my case in my own words. Appeal three quoted their own published coverage criteria back at them, clause by clause, with my documented values next to each clause in a table.
Approved eight days later. Same facts, different presentation. The lesson I take is that these decisions are made by someone matching a form against a checklist, and if you hand them the completed checklist they have nothing to decline.
Template in the comments. Take it, it is free, and there is no link because links are how this community stops being useful.
best — the order this archive was captured in
This is the single highest-value insight in the community and it took me three years to learn it too. Do not argue that you deserve coverage. Demonstrate that you meet the published criteria, in their order, in their vocabulary.
The three sentences that got mine through: state the exact criterion, state your documented value or history against it, cite the page of the plan document. Repeat per criterion. No narrative, no appeal to fairness.
"no appeal to fairness" is the part that took me longest emotionally. the narrative is what you want to write and it is the part they do not read.
and if step therapy applies, document the failure of the cheaper option properly at the time rather than reconstructing it later. dates, doses, what happened, in the chart.
reason codes are worth decoding too. most of them are fixable paperwork rather than a policy judgement, and the code tells you which.
and check the full plan document, not the summary. mine had a carve-out that appeared nowhere in the benefits summary HR sent me.
ask HR for the full document in writing. they have to give it to you and they will not volunteer it.
and once you are paying, pre-tax dollars change the real cost by about a third. i nearly missed that for a year.
Flagging the community rule since this thread will attract it: do not suggest misrepresenting a diagnosis. That is fraud, it gets you banned here, and it puts the person taking your advice in a far worse position than a denial does.
manufacturer savings programmes are worth checking monthly because the eligibility fine print changes. edit: mine changed twice in a year, both times narrowing.
reading this from the UK with a strange mixture of horror and envy. you at least had something to push against.
eleven months and three appeals is not a win
it is the only kind of win available. the alternative was zero months and no coverage.
- 1This is the single highest-value insight in the community and it took me…6 comments in this branch · started by u/appeal_letter_al