Appealing a Denied Procedure
Advanced English listening exercise ยท Health Insurance
Transcript
[Agent] Thank you for calling MediCare Plus appeals department. I'm Sandra. How can I help? [Patient] Hi Sandra, my insurance denied my request for an MRI of my knee. I want to appeal the decision. [Agent] I understand how frustrating that must be. Let me pull up your case... I see the prior authorization request was submitted by Dr. Thompson on February first and denied on February fifth. [Patient] Why was it denied? [Agent] The denial reason states that the requested procedure doesn't meet medical necessity criteria. The review indicated that conservative treatment should be attempted first. [Patient] But I've already done six weeks of physical therapy and it hasn't helped. I'm still in constant pain. [Agent] That's exactly the kind of information we need for the appeal. Here's what I recommend: Ask Dr. Thompson to write a detailed letter of medical necessity explaining your treatment history, failed conservative measures, and clinical findings that support the MRI. [Patient] What else do I need? [Agent] Include your physical therapy records showing the sessions you completed and the lack of improvement. Any clinical notes, exam findings, or diagnostic results from Dr. Thompson would strengthen the appeal. [Patient] How long does the appeal take? [Agent] For a standard appeal, we have thirty days to review and respond. If your doctor believes it's urgent, we can request an expedited review, which must be completed within seventy-two hours. [Patient] My doctor says the delay could cause further damage. [Agent] Then I'd strongly recommend the expedited route. Have Dr. Thompson's office call our provider line and request an expedited peer-to-peer review. Your doctor can speak directly with our medical director to explain the urgency. [Patient] Thank you, I'll contact Dr. Thompson right away.
Comprehension questions
- Why was the MRI denied?
- How quickly must an expedited review be completed?
- Who submitted the prior authorization request for the MRI?
- What type of documents should be included to strengthen the appeal?
- How long does the agent say a standard appeal takes to review?