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c/insurancefights·submitted 1 year ago by u/muscle_cramp_mo

help me understand appeal, I have read the wiki twice

Questionbranch of 7 comments

Genuinely asking, not being difficult. Everyone in c/labresults repeats that external review is important. I believe it, but I have never seen anyone show why, and when I search I get 10 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…

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7 comments, started 1 year ago
u/ferran_dahlberg33 points·1 year ago

prior auth criteria are state-specific, formulary differs

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u/blunt_coldbox_notes21 points·1 year ago

Not to be pedantic but denial and step therapy are being used interchangeably and they are not interchangeable in real life.

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u/cato_achebe6 points·1 year ago·edited

That is net peptide content, not purity. Different number, different meaning.

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u/saskia_lokken1 point·1 year ago

Strongly agree. Step therapy is predictable if you have the criteria.

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u/ilias_cabrera12 points·1 year ago

This is the "correlation is mechanism" thing again. You changed three variables at once.

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u/sofia_ferreira4 points·1 year ago

external review is the appeal after insurance says no

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u/ireland_drugs_pay25 points·1 year ago

resubmission after denial requires new documentation

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The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.

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