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RE: [IP] Denial of Coverage-- A vent



Who reviewed the claim for medical necessity? We have United Healthcare  and
our son's claim was initially reviewed by Health International and denied. I
would ask the following:

*	Who reviewed the claim and what are their qualifications?
*	What is the appeal process?
*	What do they base approvals on?
*	What additional information do they need?

In our case the claim was initially reviewed by a cardiologist who also does
internal medicine. Our problem with this was that the claim was not reviewed
by a Board Certified Pediatric Endocrinologist. We appealed the claim twice,
the second time it was sent out to a Board Certified Pediatric
Endocrinologist who agreed with the recommendation of our Board Certified
Pediatric Endocrinologist. I also found out what the Health International's
concerns were regarding safety, effectiveness, etc and faxed them journal
articles addressing those issues. 

It may take time and effort to get it approved, but don't give up!

Dana Barber Gonzales, MHSA
University Affiliated Program
Department of Pediatrics
2001 Pershing Circle, Ste 300
North Little Rock, AR 72114
501-682-9919
fax - 501-682-9905

> -----Original Message-----
> From:	email @ redacted [SMTP:email @ redacted]
> Sent:	Wednesday, August 08, 2001 4:46 PM
> To:	email @ redacted
> Subject:	Re: [IP] Denial of Coverage-- A vent
> 
> In a message dated 8/8/01 4:33:15 PM US Eastern Standard Time, 
> email @ redacted writes:
> 
> << I just received my letter from United Health Care denying coverage for
> the 
>  pump.
>  
>  Some of you may have some experience in this, it looks as though my only 
>  option at this point is an appeal to my employer.  If that does not go my
> 
>  way, no pump. >>
> 
> Does your policy have language in it that specifically says insulin pumps
> are 
> not covered for people with type 2 diabetes? Unless it does, I'd say it
> has 
> to cover the pump. BTW, when my endo wrote the letter of necessity, he
> never 
> said what type I am -- just that I take insulin and will for the rest of
> my 
> life.
> 
> Jan and Elvis
> (type 2, pumping)
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