This is what you get back.
Four representative letters and the decode you’d get back for each — what happened, what it means, the deadline that matters, and the reply we draft for you to review.
Services rendered on the above date of service have been adjudicated and are not payable under the terms of the member’s certificate of coverage. The requested service does not satisfy the criteria for medical necessity as set forth in clinical policy bulletin MP-2211. Member may be responsible for billed charges in the amount of $2,340.00. This determination may be subject to reconsideration upon receipt of additional documentation within the timeframe specified in your plan documents.
“I am requesting an internal appeal of the denial of claim 4471-0092. The denial cites clinical policy bulletin MP-2211. Under that bulletin, imaging is covered where conservative treatment has failed over six weeks, which my records document. I request a copy of the reviewing physician’s credentials and specialty, as provided under 29 CFR 2560.503-1.”