Wiki No Precertification - chemo drugs

[mdonapel]

Hi,
Has anyone ever run into a situation where a chemo order was changed or the pre-certification team flat out failed to get a precert for services? Has anyone had any success getting a retro-auth or appeal overturned based on medical necessity for this situation especially with Aetna and would you be willing to share the verbiage you use in your appeal letters?

Thanks in advance,
Michelle

 

[DavisA]

Hi Michelle,
In instances like that, usually the drug company can help with appeals. In order for you to use their drug usually they are willing to help getting all the prior auth, and appeal letters to help you get reimbursed. They can help with commercial plans I doubt that they can with any other government programs.
I hope this helps you.
DA