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[IP] A successful appeal to the initial Ins. Co. denial

In a message dated 6/9/2001 5:49:52 PM Mountain Daylight Time, 
email @ redacted writes:

> I was told that since my insurance company has doctors on staff to review
>  these claims, and they have licenses, they are not practicing medicine
>  without licenses.  I know that these doctors have never seen the people 
>  are approving or not approving pumps for, but they still are licensed to
>  practice medicine  . . .

Same with my Ins. Co. -- but I wonder, can we sue those reviewing physicians 
for malpractice --especially when they're making medical decisions for 
patients they've never even seen and for whom they have much less than the 
complete medical information that they should have prior to making medical 
decisions . . .

One other piece of advice about appealing your insurance company's decision . 
. . Our original pre-approval request for Katie's pump was declined based on 
the letter from her doctor (a fairly standard one , but one that has been 
sufficient for getting many other peoples pumps approved with a variety of 
insurance companies) . . . 

We called immediately and made them (the insurance company) fax us a copy of 
the criteria they use for making decisions about pumps (which they called 
their "Medical Policy").  

This information was used to frame the 2nd letter from our doc and 
specifically stated information that met their criteria (such as her having 
had frequent hyper & hypo glycemia events below/above their specific cut off 
numbers, that the "patient has demonstrated ability and commitment to comply 
with the regimen of pump care .  . ." etc. etc. ) -- by using THEIR language 
verbatim and documenting that their criteria was being met, it made it very 
obvious that they weren't going to have an easy time explaining a second 
denial . . . which didn't happen -- we got approval within 24 hours after the 
insurance company received the  doctors 2nd letter . . .

Don't give up .  .  . They've got nothing to lose by making you jump through 
hoops (in the hopes that you' will give up) -- but you have a lot to gain!!!

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