[jss]

Debbie,

I don't have the tree; however, my cousin, who was a case manager for Aetna explained it to me this way (for Aetna).

The first step in the decision tree is a big matrix, which is indexed by codes for conditions and treatments. If you're prescribed treatment is in the cell where the condition and treatment intersect, then a clerk will look at an internal process that is documented for that condition/treatment combination (and there are tens of thousands of these). If the treatment that you are pursuing is not in that cell, you are denied. If your case is unusual enough then it will be assigned to a case manager; who has limited decision making ability and can sometimes approve your treatment. The case manager will look at your case and take it before a board of doctors that will evaluate your condition, prescribed treatment and cost; then make a decision based on that. In her experience, cost was as important a factor as any in deciding which treatment you would get.

With BCBS-TX I tried for nine months to be assigned a case manager to which I could speak, but could never get my case pushed beyond the clerks that interpret the matrix.

Good luck, Jeff