Qualification of individiuals on review board.!!!

Hi everyone It is quite common for insurance companies to deny claims on the basis of lack of medical necessity. How many ppl here at obesityhelp actually requested a list of names and the medical expertise of the indiviuals *****viewed your information and determined that its not medically necessary. Alot of times documents submitted by our Physicians, Specialist....Nutritionist etc..... plus BMI makes our claims so obviously necessary. Is the medical review board a independent group of ppl that is MEDICALLY qualified to provided IMPARTIAL decisions on our claims? For all those who have had letters from PCP, experts...etc and high BMI showing a great necessity....maybe it wouldn't hurt to check out the credentials of the person making the decision to undermine your PCP's and others expertise. I read on a ERISA O&A website that patients can request the list of names and the expertise of all the individuals on the review board that contributed to the "denial decision". According to the website, the insurance must provide you with this info upon request. I don't know how true this. If anyone is more familiar with the internal dynamics of insurance companies and review boards, levels of appeals....etc. I would be happy to hear how it works. Thanks Keisha Simms

I think many of these reviews are stocked with people the insurance company knows will support their position. When I had my second level of appeal hearing (by phone) with the company, there was a woman on there who asked about my exercise habits. When I told her I walked a mile on most days, she told me she used a treadmill at an incline of 7 at 3.5 miles per hour and only burned 100 calories for a mile, so since I was overweight and couldn't be going as fast as her, she knew I couldn't be burning even 100 calories from exercise, so I wasn't doing enough to help myself. This person (who didn't even know that the higher your weight, the more calories you would burn) was considered qualified to decide on my appeal. I did ask for these names and also copies of the studies they quoted in their denials, but never did get them. However, I finally got approved yesterday in the very last stage of appeals where I got an impartial hearing at last. So don't give up!!

Hi I agree with you 100% and I am talking from experience. All, the individuals on the review board have some incentive and are making decisions in favor of the company they work for. Maybe they get a commission for finding ways to save the company money?....lol. I went through my third level of appeal, in all my denial letters their response to my claim is..."not medically necessary". They have not provided me with any scientific or clinical reason to justify this decision. I too had asked for the credentials of the MD and others used on the review board and still did not get anything. Earlier this week, I called them up and asked them to fax or mail me over a hard copy of the list of requirments. I already know what they are, but I want it from them in writing because I meet each and everything that thay require for approval. I was told that a copy of a list of criteria cannot be provided to me. Congratulations on your victory, I know getting approved is a big load off. Keep me up to date on your journey!!!!!!! Goodluck