Appeal Letter Template

[csctnmrm]

I've attached a copy of the appeal letter (MS word document) that I was ABOUT to send to BC of Idaho when I discovered that they ARE now approving for "intermittent monitoring." I'm now going to wait to see how much is actually covered before I send this to them.

Let me give you some background first ...
I've had a Dexcom since Feb 2007 and never applied for my insurance to cover it. Everything I saw said they wouldn't cover it anyway. Then after I heard they were approving on a case-by-case basis, I had my Dr/Endo office send a letter of Medical Necessity to them back in April. They sent me a form letter denial saying it wasn't covered in my policy and was investigational. I spoke to Dexcom and they had a "specialist" for this so I gave them all my info. They sent an appeal letter and once again I was denied. This time they sent a better form letter that at least specified 5 criteria for the denial.

They were:
• The technology must have the final approval from the appropriate government regulatory body. This applies to drugs, biological products, devices, and other products/procedures that must have approval from the U.S. Food and Drug Administration (FDA) or another federal authority before they can be marketed. Interim approval is not sufficient. The condition for which the technology is approved must be the same as that BCI is evaluating.
• The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes. The evidence should consist of current published medical literature and investigations published in peer-reviewed journals. The quality of the studies and consistency of the results will be considered. The evidence should demonstrate that the technology can measure or alter physiological changes related to a Disease, injury, Illness, or condition. In addition, there should be evidence that such measurement or alteration affects health outcomes.
• Technology must improve the net health outcome. The technology’s beneficial effects on health outcomes should outweigh any harmful effects on health outcomes.
• The technology must show improvement that is attainable outside the investigational setting. Improvements must be demonstrated when used under the usual conditions of medical practice.
• The technology must be as beneficial as any established alternatives.

I had some assitance with the attached letter from a man that says he has written several winning appeal letters. It's a little more heavy handed than I normally would write. I've removed the personal info and you will need to put yours in there. Be sure that you edit any other info that doesn't apply. Good luck...