Department of Labor guidance for ERISA health benefit claims explains that denial notices must give specific reasons and refer to the plan provisions on which the decision is based. Claimants can request documents, records and other information relevant to the claim free of charge.
For an expensive medicine, that can turn a vague “not medically necessary” statement into a concrete list of criteria, records and missing evidence.
- Written denial notice
- Specific plan provision
- Drug/medical-necessity criteria
- Records the plan reviewed
- Any missing records
- Identity/type of medical reviewer if available
- Appeal deadline
- Evidence responding to each stated reason
Request the decision record in writing
Ask for the specific plan provision, medical-necessity or utilization-review criteria, clinical policy, records reviewed, and any new or additional rationale used in the appeal process when applicable.
If medical judgment was involved, ask what clinical information the reviewer relied on and whether the plan obtained advice from a medical expert.
Check whether the plan reviewed the right case
Compare the decision materials with the actual medicine, indication, dose, product, treatment site and clinical history. A denial built on the wrong diagnosis, outdated note or wrong product should be corrected before arguing the merits of criteria that never fit the patient.
If required records were missing, identify who was supposed to send them and document the resubmission.
Build the appeal around the actual stated reason
Do not submit a generic letter saying the medicine is important. Address each criterion or plan provision the denial identifies and include the evidence that supports the requested treatment under the plan’s own rules.
If the plan changes its rationale during review, preserve the new explanation and the opportunity to respond that applicable rules provide.
Use the source that actually controls your case
MedicineCostHelp can organize the problem, but the member-specific plan, Medicare program, provider billing record or assistance program makes the actual decision. Save written determinations and reference numbers so the next person does not have to reconstruct the case from scratch.