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Old 10-25-2005, 01:21 AM
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I received my denial letter to my appeal with my carrier (HealthNet) the other day, and thought it might be worth posting their reasoning for the denial to see what people have heard/seen in that regard.

I appealed and provided significant backup, detail and even a HealthNet peer-to-peer review from another patient with the same condition who was approved for ADR. The HealthNet reviewer cited the FDA approval and the fact that the FDA approved with the condition that the Charite manufacturer conduct a five year investigational study on the after-surgery effects and outcomes of the device. Note the term "investigational," which they basically used to explain everything away. If the FDA requires a five-year investigation, the device is therefore investigational, they claim.

It's amazing to me the lack of consistency not only in the industry, but within one insurance carrier. In reference to the other patient who was approved, they stated that was not relevant, as their policy clearly states that appeals and decisions are on a case-by-case basis.



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