Re: BC/BS NJ Copy of Denial Letter

[Guest guest]

Barbara,

We had two letters of medical necessity from our specialist and one from our

ped. We were denied for the same reason as you. I too was baffled about how

this could possibly be. I took the angle with the insurance co when I

appealed that a doctor that was IN THEIR OWN NETWORK had given written

testimony that the treatment was medically necessary. Unfortunately I went

through three appeal levels and was denied each and every time. The place

where my letters of medical necessity really helped was when I began the

external review board process. They were the ones that overturned the

decision and forced the insurance company to pay based largely on the letters

from my specialist. Don't give up - with the backing of your doctors you have

a very good chance of winning an appeal. Check out our homepage under

insurance help for some appeal letters that won. That is where I started when

I began my first appeal letter. Also, please keep a very detailed phone log

of EVERYONE you talk to regarding the treatment - insurance co, doctor,

ortho, etc. I believe that the information I collected along those lines also

helped my case. It really showed the inconsistencies and unprofessionalism my

insurance company demonstrated.

Don't worry yet Barbara - use the frustration to become even more determined

and focused on winning this battle. You can do it! Please let me know if

there is anything I can do to help you. I think I know exactly how you are

feeling right now. Hang in there!

Marci (Mom to )

Oklahoma

[Guest guest]

Hi,

Sorry you have to go through this with the insurance.

I just went through it with BCBS of Oregon and after

my 1st appeal they overturned their denial and are

approving the DOC Band at 100%. They referred it to

an external review board and they deemed the band

" medically necessary " after BCBS said it wasn't. I

formatted my appeal letter after an appeal letter

that's listed on this group's site. It's an appeal

letter to Coventry and it's a great letter with great

peer reviewed journals and recommendations from the

AMA. Some of the info mentioned in the letter came

from CT and some of it is listed on this group' site

in the same file as the appeal letter. There's also

and 2nd appeal letter to Coventry and the second

appeal was successful. Also mention in your letter

that BCBS of NC and BCBS of Oregon and BCBS of

California has paid for the DOC Band. The " denial

letter " you received should have a phone# you can

contact to request a written explanation stating their

reasons why they denied the band. I was able to

refute a few of their reasons with the articles I

enclosed. I had 60 days to appeal from the time my

" denial letter " was sent to me. My denial letter

sounds like yours. I didn't appeal until I received

their statement why they denied me. I suggest you do

the same, so you can respond to their reasons. Good

luck!

, 's mom

Southern California

--- catasofia2002 <catasofia2002@...> wrote:

> Hi,

>

> Blue Cross/Blue Shield of New Jersey told me over

> the phone that they

> have denied treatment for my daughter Sofia. Reason

> was it was not

> a " medical necessity " . Both her Pediatrician and

> plastic surgeon

> sent in letters saying it was a medical necessity.

> Why would they

> use this as an excuse? I have not received the

> denial letter in the

> mail so I asked them to please fax it over but they

> haven't. Every

> time I call and ask for it they take my number down

> but do not return

> my calls.

>

> What else can I do to get a copy of this denial

> letter? Also, what

> is my fist step in appealing their decision?

>

> I'm in tears every time I hang up the phone with

> them. I cannot

> understand how cold they can be especially when it

> comes to treatment

> for a baby.

>

> Barbara (Sofia's mommy)

>

>

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