Flector 1.1: A Case Study

The patient is informed about their coverage and the amount of copayment they would have to pay.

“This article discusses how Medicare Carriers and Fiscal Intermediaries use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected to not meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the

You must follow plan rules, like getting a referral to see a specialist to avoid higher costs if your plan requires it. The specialist you're referred to must also be in the plan's network. Check with the plan.

The carrier has denied coverage of Harvoni 90mg – 400mg as not medically necessary. There is a letter from the carrier to the member dated 11/20/2015, which states in part:

Please note that BCBSIL is not denying coverage for Nasser Shamah to receive treatment with Dr. Klein-Gitelman. We are advising that Dr. Klein-Gitelman is Non-Participating in the Blue Choice PPO network and that the Non-Participating provider benefits will apply. As always, treatment decisions are the responsibility of the patient and the attending physician, not BCBSIL or the Benefit Plan.

made exclusively and directly by the patient to the physician. The request cannot be made on

The carrier has denied coverage of scleral lenses as not medically necessary. A letter from the carrier to the member, dated 06/02/2016, states in part:

The claimant has a past medical history significant for fibromyalgia, fatigue, arthritis, chronic pain, joint pain, leg pain, frequent urination, and swelling.

For eligible Medicare Part D patients who cannot afford their copayments or co-insurance for Renvela.

The carrier has denied coverage of FDG-PET scan as not medically necessary. A letter from the carrier to the member, dated 05/08/2016, states in part:

This 72-year-old claimant sustained a work-related injury on 04/22/07. The claimant continues to have discomfort in the right thigh, buttock area, and lumbar spine. She has a pain rating of 2-7/10. She takes Voltaren more regularly and the Tylenol only when the pain is greater. It was noted that she has been taking these medications for years with benefit. The claimant’s pain has decreased and the claimant is able to complete activities of daily living with the use of medications. However, this medication is listed as a “Non-Preferred” drug in the formulary. There is no documentation of failed trials of “Preferred” drugs and documentation indicating that this medication is more beneficial to the claimant than a “Non-Preferred”

Samantha is a 47-year-old female who suffers from RR multiple sclerosis (G35), along with a history of pelvic fracture, neoplasm of pituitary gland and craniopharyngeal duct, vitamin D deficiency, and chronic fatigue. Samantha has tried and failed various treatments including betaseron, copaxone, tecfidera, and rebif, all have provided her with minimal remission from her symptoms. The denial states Aubagio is not on the plan’s formulary. We are requesting an exception for the Aubagio to be covered or added to the plan’s formulary. Samantha is currently stable on Aubagio with no ill side effect, therefore it would be ill advised to deny Samantha coverage for a treatment that is currently controlling her symptoms. Forcing her to change to a medication

There are many reasons why Mark Flannery's insurance claim could have rejected last month. The bill could have been sent to the wrong insurance office. Mark's demographic information could not have been accurate when the claim was submitted. The effective date of coverage could cause a claim to reject if the insured's date of service was beforehand. Although the diagnosis codes were correct was this service covered by Mark's insurance plan? Mark may need a prior authorization for the service he received if it was covered. Not verifying insurance initially can cause a lot of problems resulting in rejected claims and also improper claim submittal. There are specific guidelines when submitting claims and timelines to follow in order to receive payment from insurance company's.In order to handle Mr. Flannery's angry call, Lewis should remain calm and professional. He needs to assure Mr. Flannery that he will look into why the claim was rejected and not just assume that he is responsible for the service costs. Lewis should provide Mr. Flannery with

“…The patient’s benefits plan excludes coverage for services that are deemed no medically necessary as

The carrier has denied coverage of inpatient psychiatric treatment at Norristown State Hospital from 12/22/2015-12/28/2015 and 12/30/2016 going forward as not medically necessary. There is a letter from the carrier to the member dated 02/23/2016 which states in part: