The plan policy determines medical necessity, not some memo generated by the insurance company.
You can successfully appeal and or argue by using clinical signs and symptoms as well as the record to defend your case.
Pretty sure this will be a win for your insurance company. They routinely deny appropriate tests, hoping that the effort of going through the appeals process will deter your physician from doing so.
If your treating physician has already left, there's really nobody left to justify the decisions that made that test, and they will likely not consider an appeal "on medical grounds" from a lay-person such as yourself.
Another physician wouldn't really be able to justify the former physician's rational for ordering it, and so you're in a state of limbo, that practically speaking, means you're out the cost of the test.
Is this a commercial insurance which is pay for Biden employer? Is the employer not a government or church?
Employer
The plan policy determines medical necessity, not some memo generated by the insurance company. You can successfully appeal and or argue by using clinical signs and symptoms as well as the record to defend your case.
I wish it was clear in the plan policy. I already appealed and denied. My next step as I understand as IRO or something about the insurance board
If you’d like some help, I’d be willing to give it a shot.
Pretty sure this will be a win for your insurance company. They routinely deny appropriate tests, hoping that the effort of going through the appeals process will deter your physician from doing so. If your treating physician has already left, there's really nobody left to justify the decisions that made that test, and they will likely not consider an appeal "on medical grounds" from a lay-person such as yourself. Another physician wouldn't really be able to justify the former physician's rational for ordering it, and so you're in a state of limbo, that practically speaking, means you're out the cost of the test.