So let me see if I've got this straight...

[Ms. Toad]

261. Phone calls aren't the same as an appeal.

And doctors' offices (even when they are wonderful from a medical practice perspective) sometimes screw up royally with insurance.

I went through this run-around with one of my spouse's medications. There was a very simple process to get the medication covered. It was in our certificate of coverage. I gave the information to my spouse to get it to her doctor (who is a medical miracle worker, and should have enough administrative experience to have found it on his own). They kept telling my spouse they had appealed and it had been denied. Repeatedly. I would call the insurance company (I interface with the insurance companies for everyone in our family), and they kept telling me there had been no appeal.

It turned out that the doctor's office had just been repeatedly faxing the prescription in without the paperwork necessary for this particular step medication (one which has to be a second choice, when something else failed). They told my spouse that they had repeatedly called and had been repeatedly denied, but could not give me a claim number (which would have been generated if it had actually been appealed and denied). I finally was able to initiate the review process through the insurance company, who got the doctor's office on the phone - and the prescription was approved that day.

In this case, it was the initial approval for step-therapy, not an appeal. But don't just take your doctor's word that they have gone through the proper process. Read your certificate of coverage. Talk to the insurance company. Make sure, first, there isn't a simple internal way to get the medicine covered. If not, find out the formal appeal process and insist the doctor follow through - or fire the doctor. (We have had to fire one doctor who refused to help us through the appeal process - it really is something you need a strong doctor advocate for.)

Good luck.