I thought I heard it all for UR denials but (California) (Ca

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I thought I heard it all for UR denials but (California) (Ca

Postby mk61347 on Thu Mar 12, 2015 2:48 am

I requested authorization for a PTSD group for a patient who experienced a severe PTSD trauma.

The reviewer denied the treatment stating that there was no indication that I had evaluated whether the patient was ready to participate in group therapy.

I did in fact discuss this and the patient was eager to participate. He expressed an opinion that he felt that only another PTSD could really understand what he ahd been through.

But what is incomprehensible to me is why would I refer a patent for treatment unless I thought it was appropriate and the patient was ready.

But it gets better.

I called the nurse who referred the patient to me. She called the claims examiner who stated she would not override the ur decision.

So the nurse called the UR dr back.

After each missing each other on a call, the UR dr called me back and continued to deny group therapy after reviewing her original decision. She then also reasserted her position of authorizing 6 of the 12 individual psychotherapy sessions I requested. She then authorized 4 sessions of Biofeedback. I did not request this. Additionally what evidence does she have that the patient is "ready" to participate in BFT. The patient has had over ten major surgeries for broken body parts, needs more surgeries, and is not able to sit still long enough for BFT nor does he want BFT
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Re: I thought I heard it all for UR denials but (California) (Ca

Postby LawAdvocate on Fri Mar 13, 2015 9:23 am

Patients frequently do not want what is best for them. Biofeedback is an immensely helpful tool in treating PTSD. I was pretty busted up and sitting still, did not impact my ability to benefit from the biofeedback.
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Re: I thought I heard it all for UR denials but (California) (Ca

Postby Barney5 on Sun Mar 15, 2015 2:26 pm

I understand that UR can modify a request, but did not know they can opine and suggest an entirely different type of treatment (example biofeedback).


I think the situation you wrote about could be remedied by a written appeal to the UR company through their internal UR appeal process. Everything the UR doctor stated to deny your requests, you can address in writing and it can overturn the denial with a letter of appeal (if it is still within time period to appeal).

Each UR company has their own UR appeal process and it is stated on the last few pages of the UR denial. There are time limits to do these UR appeals. After that, the patient, their attorney or their doctor can request an IMR. Many are not using the internal UR appeal process. If the rational to deny is not addresses in writing with a UR appeal or to IMR...the IMR reviewer will just use the UR denial rational and rubber stamp it (most of the time).
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Re: I thought I heard it all for UR denials but (California) (Ca

Postby mk61347 on Fri Sep 04, 2015 4:42 am

I did second appeal and UR upheld original decision. With my appeal I sent documentation that patient attended first group session and greatly benefited . Patient stated after group that he felt only another PTSD patient could understand what they were going through and they felt less negatively about themselves because it helped to see others also had difficulties managing effects of trauma. Pt had fallen over 25 feet on to cement and lived.

Atty sent to IMR but requested the reduction of my request for 12 sessions to six sessions be reviewed. I called atty and told them my appeal was for group therapy not additional sessions. I asked them to amend their request. They did not. IMR then stated they would not review issue of group therapy since atty did not request.

Happy ending . Since IMR did not review group therapy, I requested retroactive approval of group therapy on the basis of additional information since first request, Approval was granted by ins co UR
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tutors

Postby james007wash on Fri Jan 01, 2016 10:07 pm

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Re: I thought I heard it all for UR denials but (California) (Ca

Postby Barney5 on Sat Jan 02, 2016 8:40 pm

Nice to read your patient got an approval in the end.

Reading back on this post it reminds me of the many UR denials I have seen that are a boiler plate denial on basis x.y,z was not attempted first, when in fact it had been. In some cases the information was sent to the review but never read or mentioned in the denial and many cases the information was not sent. So these denials are being done with lack of information. For those on the applicant side you can make another request to UR when this happens under the basis of new information even after IMR has denied it and do not have to wait 12 months. There is a box for this on the RFA.
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