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

It seems the only way you could have a successful case against the
doctors was if they gave a wrong judgement based on the information they
had.  You are responsible for getting them the data they need.

Using the companies own language in a letter is probably the best way to
deal with them.  Also using your own policy's language is helpful too. 
You have to show them why they are responsible for supplying this pump
based on the policy which is really a contract.


On Sat, 9 Jun 2001 21:34:03 EDT email @ redacted writes:
> 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 
> they
> >  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!!!
> Lyndy
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