Appealing a claim, don’t be afraid to know what you are talking about.
Some strategies to use for ensuring a peer review are the following:
- Provide the treating physician’s background and specialty credentials. Follow this with a request for the credentials of the Payer’s clinical reviewer. Cite the URAC definition of a peer reviewer.
- Provide clinical specifics about the patient’s specific conditions/problems and how it might differ from a typical patient needing the care in question.
- Provide a detailed listing of failed conservative care treatments and medications (include dosages)
- Provide approximate number of times that the treating provider has performed the procedure/treatment in question
- Provide specifics about the treatment conversation with the patient and the patient’s response to this treatment availability.
- Provide a copy of FDA approval/clearance letter along with all available clinical guidance relating to device/procedure.