The doctor is a traitor to clinical care, and a clueless dunce. Evidence based medicine is the medicine of 7 years ago, after academia has caught up with their research paper shuffling. It represents deviations from current standards of due care, but a convenient pretext to deny care by traitors to clinical care.
Appeals are totally rigged against spending by insurance, and phony time consuming procedures.
Here are other ideas to get approval.
1) Keep submitting or calling about approval. Eventually, a low level reviewer will randomly approve the request. Most of the decision are inappropriate and driven by personal profit from denial of care. This doctor should tell us whether he gets bonuses from company profits.
2) Have a standard letter to be signed by a patient. When these insurance company collaborators deny adequate care, send a formal request for an investigation by the licensing board. If the doctor is out of state, not licensed in the state of the patient, the denial of care is a medical act, requiring a license. Submit a request for an investigation into the unauthorized practice of medicine.
If the doctor is licensed in the state of the patient, but qualified outside the specialty of the prescriber, ask for an investigation into practice outside the scope of training and knowledge.
If the reviewer is licensed in state, and deny care within his own specialty, ask for an investigation into a medical act taken without direct evaluation of the patient, on an unknown patient. Records are not transcipts, so they are not adequate substitutes for a thorough evaluation in person by the reviewer.
3) If there will be a difference in pay, refer to the Department of Justice for a violation of the Stark Amendment and Anti-Kickback statutes.
2 years ago