unpopular opinion: most of what gets said here about denial is guesswork
The title is the argument: unpopular opinion: most of what gets said here about denial is guesswork. Here is the rest of it. 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…
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
external review exists and almost nobody uses it
a peer-to-peer call is often faster than a written appeal
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
the formulary is published, read it before you appeal
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
keep every date, every reference number, every name of a department
deadlines run from the letter date, not from when you opened it
deadlines run from the letter date, not from when you opened it
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
a template letter that quotes their own criteria back is the strongest one