Appeal Letters

[Kim]

Hi
Several are in the process of appeals for approval for ADR. I wondered if any of you would share your appeal letter with me? I am working on my first and am trying to get a scope on what others have done.
Thanks in advance
Kim

[Harrison]

Kim, the process can be a real drag...see one of my appeals I posted last week in this forum here.

[sfmcfar]

Kim,

I'm new to the appeal procedure - I'm hoping I won't have to appeal, but I'm already getting my guns lined up - but here are my thoughts.

First, keep your letter professional. The less emotion in our letters the more likely I think they take us seriously. Besides, appealing to their sympathy won't work anyway.

Second, follow your carrier's appeal instructions to the letter. Make sure you send everything registered mail with return receipt requested.

Third, try to use their own words against them. For example, if they say that it's "experimental and investigational" find out what their definition of "experimental and investigational" is, and then, point by point, present evidence to refute (FDA approval, ten year French studies, etc, etc).

If they still deny your appeal, which is always a distinct possibility, find out what recourse you have with the State of Tennessee (where do yo live? I was born and raised in Knoxville). For instance, in the State of Maryland, we have the right to appeal to an independent review board, and on Friday I heard that the Maryland review board recently forced a carrier to pay for ADR. Independent boards (I think) are much more likely to reverse a decision than the insurance companies themselves.

Hope this helps,

-stan

[Kim]

Harrison and Stan thanks
I have requested that they send me the guidelines they used to say the surgery is still investigational and experimental so I can refute them.
I figure I cant fight a decision if I dont know how they based their decision. I hope that they provide me the info.
Another member here has had a hard time getting their ins to come up with anything concerning this.
I am just west of Nashville Stan but grew up in the Cookeville area about half way between Nashville and Knoxville.
Kim

[sfmcfar]

Kim,

make the sure the plan documentation doesn't have the definition of investigational and experimental in it already - I know the my MAMSI plan has it listed in their defintions. Also search your plan's webiste - sometimes they'll have a list of definitions and include "investigational and experimental."

And if they don't send you a definition, maybe you can use that against them as well. Explain in your appeal that you requested the plan's definition, and never received one, so you'll have to apply your own definition...

[Kim]

The HR lady called me today and told me Great West was sending me the guidlelines that I had asked for. Now lets see if I get them. I will look at the website in the meantime also that is a good idea, thanks!
Will let you know what I find or if I get them in the mail.
Kim

[bmills]

Harrison, at what part of the process did yours get approved? Was it the first appeal or what?

Thanks!

Brady