Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 Hi : I am currently working on an insurance appeal with BCBS of Texas where they are denying coverage for HBO. They paid for it in the past with no problems. In fact, they covered about 135 treatments (129 treatments in May 99 through Sept 99 and 6 treatments in April of 01). They are denying coverage for approximately 100 more treatments dating from Sept 2000 through September 2001. The denial letter states: " Our review determined that the services (PC-99183) requested is Experimental / Investigational based on the following: The information submitted. The medical necessity requirement of the Benefit Plan for these reviews. The clinical basis for this determination is as follows: " Denial Reason - Services not effective for diagnosis / treatment of condition. " " The source of screening criteria utilized as guidelines in making this determination was Blue Cross and Blue Shield of Texas Medical Policy Guidelines, which are developed by Blue Cross and Blue Shield of Texas Medical Division and which takes into consideration views of the state and national medical communities, the guidelines and practices of Medicare, Medicaid, or other government financed programs, and peer review literature. " I am working on the appeal now and would like any input that you or the group may suggest that could be helpful. I have had my hands full this year because my son has been sick and my timeline is running out. I am going to work on putting it together in a 3 ring binder with dividers similar to your Georgia appeal and hopefully send it Fed-Ex this coming week. Any help, thoughts, suggestions, or individual cases would be greatly appreciated. Sincerely, Tammy Quote Link to comment Share on other sites More sharing options...
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