L
Lawson
Guest
Med-legal advice needed for appeal w HMO re. refusal for child to seek specific medical specialist outside of plan that plan does not employ. In house specialist referred us to such physician but non medical director refused consult to go through b/c 1. type of plan does not cover outside MD's although same plan allowed outside MD for previous unrelated problem with a specialist they do not employ. 2nd reason given was "cosmetic" as determined by non-med director although no x-rays, molds or other dx work done on the outside was requested for review although offered. Any advice of how to approach this appeal would be appreciated.
By the way, after months of trying to get the HMO to answer our request we went ahead with the consult and concurrent surgery. The amt we are trying to recover is 20K. The physician who has done the surgery has been paid by this health plan for similiar surgeries. We were given the name of one of the plan's physicians whose child had similiar surgery and was reportedly paid by the plan. I have no documentation of such only that this physician was a gd reference for the specialist.
By the way, after months of trying to get the HMO to answer our request we went ahead with the consult and concurrent surgery. The amt we are trying to recover is 20K. The physician who has done the surgery has been paid by this health plan for similiar surgeries. We were given the name of one of the plan's physicians whose child had similiar surgery and was reportedly paid by the plan. I have no documentation of such only that this physician was a gd reference for the specialist.