[Teresa]

CindyLou,
You are right on target!! It is the employer that makes the final decision, which is precisely what I said in #5 above. However, the employer is influenced by all the other players which is why you need to know the data they are using to substantiate their denial. As you put it "know who your enemies are." However, often the employer does not know the specifics of the appeal. Therefore, it is your job to provide them (the employer) data that will make them question the "wisdom" of the TPAs recommendation not to pay for the procedure. Quite frankly the easiest way to get the employer's attention, is to show them with hard cold facts that it will save them money.

As far as the DOL telling you that they must provide you copy of the SPD within 30 days, please refer to this paragraph which is taken from the DOL article I posted earlier:
"ERISA also requires that SPDs be updated periodically. Furthermore, ERISA requires disclosure of any material reduction in covered services or benefits to participants and beneficiaries generally within 60 days of the adoption of the change through either a revised SPD or a summary of material modification (SMM). Material changes that do not result in a reduction in covered services or benefits must be disclosed through an SMM or revised SPD not later than 210 days after the end of the plan year in which the change was adopted."

The key here is if the change did not result in a reduction of services or benefits, then they have up to 210 days. So I would suggest you get a copy of the prior year SPD as your starting point. At least you would have something in writing. Many employers have a HR section on their Websites for employees where you find policy and procedures, vacation formulas, grievance policy, etc. I would check there first. If you can not locate it there, then put your request in writing to the HR Director to provide you a copy of the SPD for the prior plan year until such time that the new SPD is published. Also, request any amendments that have been made to the SPD. Most updates/changes are done by Amending the Original SPD which in fact may have been drafted years ago. As an example my employer's SPD was drafted in 2003. There has been no new SPD published; however, there have been many amendments published.