AppealLettersOnline.com Letter Title: Request For Anesthesiology Peer Review
It is our understanding that this treatment was denied pursuant to medical necessity or other specialty care policy or plan coverage limitations. The explanation of benefits did not give adequate information to establish the accuracy of this decision. Therefore, please provide the following information to support this adverse determination.
It is our position that the treatment under consideration involves specialty care and decisions concerning the appropriateness of this treatment should only be made by a board-certified anesthesiologist. Therefore, we request a anesthesiologist review within 15 working days of this request. Please have the anesthesiologist responsible for the review address the clinical review criteria used to assess this treatment, how the treatment failed to meet this criteria and what alternative course of treatment is recommended. If benefits remain denied, please provide the following information which should have been properly disclosed with the initial denial:
Name of the board certified anesthesiologist who reviewed this claim and a description of any applicable advanced training or experience this reviewer has related to this type of care;
Board certified anesthesiologist’s recommendation regarding alternative care;
A copy of applicable internal clinical guidelines applied, if such exists, and the date of development;
An outline of the specific records reviewed and a description of any records which would be necessary in order to justify coverage of this treatment;
Copies of any peer-reviewed literature, technical assessments or expert medical opinions reviewed by your company related to treatment of this nature and its efficacy;
It is our position that failure to provide the requested information may violate state and/or federal claim processing disclosure laws or, in the minimum, non-disclosure reflects a poor quality medical process which discourages treatment provider input. Disclosure standards are meant to ensure that all qualified parties have access to the information necessary to properly appeal an adverse determination. Therefore, we appreciate your prompt, detailed response to this request.
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