the denial question that gets asked weekly, answered properly
Genuinely asking, not being difficult.
Everyone in c/labresults repeats that prior authorization is important. I believe it, but I have never seen anyone show why, and when I search I get 17 threads of people agreeing with each other.
Is there a paper? Is there a measurement? Or is this one of those things that is true because it has been repeated since 2023?
I am not trying to be the "source?" guy. I would just like a source.
best — the order this archive was captured in
Removed a chain here. The rule is one line long and it is not negotiable.
Denied for prior auth, resubmitted with step therapy documentation, approved on appeal. The criteria exist, you just have to meet them.
Yeah, the denial code matters, it tells you what to fight.
Poland plan: step therapy required 6 medications first. Did them all, got approval. The order matters.
Inter-lab variance on this kind of assay is routinely 1–2 points. Different column, different gradient, different integration.
Small correction: the trial was 9 weeks, not 6. Does not change your point but people will quote it.
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redact member ids and group numbers from every screenshot
This is correct. Appeal letters work.
Not to be pedantic but denial and formulary are being used interchangeably and they are not interchangeable in real life.
Strongly agree. Step therapy is predictable if you have the criteria.
External review overturned the denial. Took 23 weeks but the process exists.
Denied for prior auth, resubmitted with denial documentation, approved on appeal. The criteria exist, you just have to meet them.
I am going to push back on this slightly.
formulary exclusions are negotiable sometimes
denial reason codes matter, ask for the actual code
Copay was denial for the copay then another 6% of the total. Read the actual plan document.
Which state? Coverage varies.
redact member ids and group numbers from every screenshot
Did you get step therapy or outright denial?
step therapy documentation is the weapon, use it
That is net peptide content, not purity. Different number, different meaning.
appeal letter templates are in the wiki
appeal letter templates are in the wiki
Adding to this: external review is doing more work than the comment implies.
- 1Copay was denial for the copay then another 6% of the total. Read the actual…8 comments in this branch · started by u/adaeze_cabrera
- 2Removed a chain here. The rule is one line long and it is not negotiable.4 comments in this branch · started by u/step_therapy_s