mamasbabygirl Posted March 30, 2006 Share Posted March 30, 2006 Dear Appeals Committee, Please accept this letter as Sandra Benton’s appeal to Anthem’s decision to deny coverage for additional skilled nursing rehabilitation. It is my understanding based on your letter of denial dated March 21, 2006 that this service has been denied because: Your review indicates that this service could be performed in a less comprehensive setting: because the member has failed to make any progress in a skilled nursing facility setting. As you know, my wife Sandra had brain surgery on January 9, 2006 and then again on February 27, 2006. Currently Dr. Robert Warnick, her neurosurgeon, believes that Mrs. Benton will significantly benefit from additional rehabilitation services. Dr. Warnick is a specialist in neurosurgery with U.C. Physicians. Please see the enclosed notes from Sandra’s last visit with Dr. Warnick that discuss my wife’s significant progress in more detail. At the time of my wife’s post operative visit, she clearly demonstrated vast improvement in her mobility since the time of discharge from the hospital. As a 51 year old woman, her ultimate goal is to return to her home environment and family. Additional rehabilitation services to strengthen her upper body would enable her to transfer independently or with assistance from just me. While we recognize a step down to a less intensive setting is standard and the normal progression, we feel that she is being transitioned prematurely. Safe transfers are of utmost concern as she returns to her home environment. Although she has received multiple therapies in the past, my wife is currently stable with her metastatic disease, is extremely motivated and determined to return to her home and live a productive life with the least amount of assistance possible. We believe that you did not have all the necessary information at the time of your initial review. We have also included with this letter, a letter from Dr. Brian Mannion, her oncologist from Cincinnati Hematology Oncology. His letter discusses the primary disease which has been stable since April of 2005. Also included is a copy of the pre-operative CT scan report citing her stable lung disease. Based on this information, we are asking that you reconsider your previous decision and allow coverage for additional rehabilitation therapy Dr. Warnick outlines as medically necessary in his notes. Should you require additional information, please do not hesitate to contact Sandra or myself at ...We will look forward to hearing from you in the near future. Quote Link to comment Share on other sites More sharing options...
Ry Posted March 30, 2006 Share Posted March 30, 2006 My only suggestion would be a list of cc's to others you are sending a copy to such as the insurance regulator, your attorney, and your congressman or representative. Might help. Quote Link to comment Share on other sites More sharing options...
mamasbabygirl Posted March 30, 2006 Author Share Posted March 30, 2006 Great idea Rochelle. Thanks!! Quote Link to comment Share on other sites More sharing options...
ginnyde Posted March 30, 2006 Share Posted March 30, 2006 Based on this information, we are asking that you reconsider your previous decision and allow coverage for THE additional rehabilitation therapy Dr. Warnick outlines as medically necessary in his notes. Should you require MORE information, please contact Sandra or myself at ...WE HOPE TO RECEIVE YOUR RESPONSE SOON. Good letter, I would insert the word 'the' for clarity. Just some other ideas. The fewer the words, the easier for the person to read. I agree with RY, I would CC everyone. Quote Link to comment Share on other sites More sharing options...
Linda661 Posted March 30, 2006 Share Posted March 30, 2006 ...We look forward to your favorable response soon... The letter looks great Lori. Indicating you expect a favorable response is something I always do with inquiries. Big yes on the cc thing as well. Linda Quote Link to comment Share on other sites More sharing options...
mamasbabygirl Posted March 30, 2006 Author Share Posted March 30, 2006 I LOVE YOU GUYS!! Quote Link to comment Share on other sites More sharing options...
purplelady47 Posted March 30, 2006 Share Posted March 30, 2006 I have worked medical accounts receivable, claims and denials for over ten years, so I have some insight on this stuff. My suggestions are: 1. Send the letters certified, return receipt requested. 2. Rather than saying "We will look forward to hearing from you in the near future.", I would say "Since time is of the essence in order to ensure maximum response to rehab therapy, I look forward to hearing from a member of your staff as soon as possible. I am aware that this appeal must go through certain channels for approval. I am that requesting that this appeal be expedited to ensure the quality care that your insured deserves. I will contact you within 5 days of your receipt of the appeal to follow up on your response." 3. Maybe using the phrase "activities of daily living"...that's always a good one. Perhaps "The goal of further rehab therapy is to give Sandra the potential to return to many of her activities of daily living, which she enjoyed prior to her surgeries. Without this therapy, that goal is not possible." Hope this helps some!! Best of luck to you! Pam in FL Quote Link to comment Share on other sites More sharing options...
MalouDP Posted March 30, 2006 Share Posted March 30, 2006 You might want to add a word "Medical Necessity" Fit this in there somewhere. Quote Link to comment Share on other sites More sharing options...
mamasbabygirl Posted March 30, 2006 Author Share Posted March 30, 2006 I can feel the love. Thanks guys.. Quote Link to comment Share on other sites More sharing options...
Snowflake Posted March 30, 2006 Share Posted March 30, 2006 I would suggest adding her insurance agent or HR department of the job supplying her insurance. If a company that supplies insurance to their employees is not happy with the service they are receiving from said insurance company, they may decide to change carriers - for the ENTIRE group of employees. Follow the money.... Good luck, Becky Quote Link to comment Share on other sites More sharing options...
Kasey Posted March 30, 2006 Share Posted March 30, 2006 Thank you in advance for your prompt attention to this matter. Quote Link to comment Share on other sites More sharing options...
Ann Posted March 30, 2006 Share Posted March 30, 2006 Your letter is very good and convincing. I love all the ideas that have been added. We have a very smart group of people here. Best of luck in getting your approval. Quote Link to comment Share on other sites More sharing options...
mamasbabygirl Posted March 30, 2006 Author Share Posted March 30, 2006 May I add that they are not only smart, but DMAN GOOD!! I am so thankful I can count on you guys. Quote Link to comment Share on other sites More sharing options...
J.C. Posted March 30, 2006 Share Posted March 30, 2006 Lori, I would send a copy to Dr. Robert Warnick and Dr. Brian Mannion and put their names in the cc list. Very good letter, Good luck Jackie Quote Link to comment Share on other sites More sharing options...
Don M Posted March 30, 2006 Share Posted March 30, 2006 Wow Lori, what a great response you got from people. If I ever have to write an appeal letter, I know where I am going for review. I can't think of anything to add. Don M Quote Link to comment Share on other sites More sharing options...
shineladysue Posted March 31, 2006 Share Posted March 31, 2006 Lori, I'm sending some prayers to help it work. Go get em girl. Love, Sue Quote Link to comment Share on other sites More sharing options...
MilliBr1 Posted March 31, 2006 Share Posted March 31, 2006 No suggestions, but saying prayers. Quote Link to comment Share on other sites More sharing options...
Mskim Posted March 31, 2006 Share Posted March 31, 2006 It a great letter Lori. Great Job! Continued Prayers, Love Kim Quote Link to comment Share on other sites More sharing options...
mamasbabygirl Posted March 31, 2006 Author Share Posted March 31, 2006 One last question purple lady, should I add some of her daily activities? I.E. jewelry making, playing board games with her grandchilren Thanks in advance!! XOXOX Off to the Dr. and hopefully a fun day out with mom. It's raining Quote Link to comment Share on other sites More sharing options...
purplelady47 Posted March 31, 2006 Share Posted March 31, 2006 Yes, it would be a good idea to add those activities, as well as her self care activities too. Hugs to you, Pam in FL Quote Link to comment Share on other sites More sharing options...
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