Re: Got The Expected Insurance Denial, Question About The Reason

[Guest guest]

Surgical screening? That sounds a little out of place. I would call

your state insurance commissioner's office and ask for some help.

That is why you pay taxes, for their help. Keep us posted, Natasha

> Hi,

>

> My son was banded (DOC band) October 14 and we just this week

received the

> insurance denial. Of course this really came as no surprise,

however, we had expected

> a much more specific reason for the denial. The reason given was

that the request for

> durable medical equipment was denied because the clinical

information submitted

> does not meet their surgical screening criteria. The letter also

stated that they will

> provide us with a written explanation of the criteria used to

evaluate the request. It

> also stated the request was rejected by their physician reviewer.

We have the right to

> appeal obviously. Is the next step to simply ask for the criteria

used to evaluate the

> request so that we can see specifically why it was denied so that

that we can fashion

> our appeal around that (assuming that we can figure out from the

criteria exactly why

> it was denied)?

>

> Thanks,

> Mark ('s dad)

[Guest guest]

Hi Mark,

Definetly get the written explanation of the denial. They may just

need more info on the band and why it is medically neccessary to

allow coverage. If you have a copy of your policy - check your

coverage under durable medical equipment. It may give you an idea of

what their criteria is. Some DME equipment are considered " surgical

supplies " , so that may be why they use the term " surgical screening

criteria " . Once you get the written denial you'll know more.

Please post again and let us know what happens.

> Hi,

>

> My son was banded (DOC band) October 14 and we just this week

received the

> insurance denial. Of course this really came as no surprise,

however, we had expected

> a much more specific reason for the denial. The reason given was

that the request for

> durable medical equipment was denied because the clinical

information submitted

> does not meet their surgical screening criteria. The letter also

stated that they will

> provide us with a written explanation of the criteria used to

evaluate the request. It

> also stated the request was rejected by their physician reviewer.

We have the right to

> appeal obviously. Is the next step to simply ask for the criteria

used to evaluate the

> request so that we can see specifically why it was denied so that

that we can fashion

> our appeal around that (assuming that we can figure out from the

criteria exactly why

> it was denied)?

>

> Thanks,

> Mark ('s dad)

[Guest guest]

Hi Mark,

How is doing? Sorry to hear about the insurance. We had a

very similarly vague wording on one of our denials, but I can't

remember exactly. We have BCBS HMO (Can't remember what you have)

and they did eventually pay for both bands. We never actually had

to officially appeal though, so sorry I can't be of much help. The

first one was paid for because of media pressure and the second was

paid for basically on my arguing it was a continution of treatment

and BCBS accidentally changing their policy on their website to

cover DOCbands (that has now been fixed-oops!). I wish you luck. I

know it's hardly another thing you want to be dealing with. When do

they think he'll graduate? I hope he gets out of it before the snow

gets too bad and really gives you some traveling headaches! Say

hello to Krista and Lynne for us.

, mom to Hannah, DOCgrad

Cape Cod, Ma

> Hi,

>

> My son was banded (DOC band) October 14 and we just this week

received the

> insurance denial. Of course this really came as no surprise,

however, we had expected

> a much more specific reason for the denial. The reason given was

that the request for

> durable medical equipment was denied because the clinical

information submitted

> does not meet their surgical screening criteria. The letter also

stated that they will

> provide us with a written explanation of the criteria used to

evaluate the request. It

> also stated the request was rejected by their physician reviewer.

We have the right to

> appeal obviously. Is the next step to simply ask for the criteria

used to evaluate the

> request so that we can see specifically why it was denied so that

that we can fashion

> our appeal around that (assuming that we can figure out from the

criteria exactly why

> it was denied)?

>

> Thanks,

> Mark ('s dad)