[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,…
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.