Is there a way to find out the criteria for covering procedures/medications?
Example 1: Doctor prescribes drug A, not effective and the drug B. Insurance denies B, saying B only approved after C & D are tried first. Many weeks lost. Would have been nice to know in advance!!
Example 2: Odd persistent pain, but X-rays show nothing. Doctor hastily makes questionable diagnosis anyway and says 6 weeks physical therapy required before any further diagnostic can be covered.
Thus a dilemma:
– Slog through 6 weeks of PT expense and delay in the hopes of an MRI or such finding the real problem months later?
- Find a better doctor but might their hands be tied too?
I’ve had other MRIs in the past that didn’t seem to require any prior ceremony. Doctor ordered, insurance covered. Is it not always like this with the same plan?
Also have seen way too many specialists that couldn’t find a glowing billboard at night even if it fell on them.
Medical procedure coverage/flowchart?
byu/ssczoxylnlvayiuqjx inInsurance
Posted by ssczoxylnlvayiuqjx
2 Comments
No, such guidelines are considered proprietary company data and can vary between carriers.
Yes, most carriers do post most medical guidelines online under the provider section. For example, you can find out what the medical guidelines for Botox for migraines or back surgery.
However not all medical guidelines under the sun will be posted.
This can be complicated as employer group plans can chose what and how they cover things that is not mandated by law.
Some carriers do post medical guidelines prescription but its hard to find… If you are a customer already of the carrier you do have the right to ask for medical guideline that you are looking into.