National Eating Disorders Association

The arguments for appeals will be similar if not identical to the arguments provided in the above section. So, in addition to the arguments already given, here are some tips for filing appeals:

  1. Request the specific reason for denial in the first place. Many reviewers will just cite “does not meet criteria for medical necessity” as a reason. This is not good enough. Ask for specific criterion that is not being met in the reviewer’s opinion. This will help you formulate a more concise argument for the appeal.
  2. Request a copy of the medical necessity criteria being used to make the determination. If they direct you to the website, ask them to guide you to the correct page over the phone (It can be very difficult to find online and I have spoken to plenty of reviewers who struggle to find it themselves). Having the exact terminology and wording at your disposal will also help you to formulate a counter-argument.
    • a) Make sure they are using ED-specific criteria if they have it. If they are not, you can make plenty of arguments as to why it is not an appropriate measure for ED treatment.
  3. Request for the next reviewer to be an ED specialist. They may not always grant the request, but it does imply that a non-ED doc may not fully understand the clinical factors involved in determining the appropriate course of treatment.
  4. Request an expedited appeal. This will speed up the process and reduce the risk of financial loss if additional treatment is not authorized.
  5. Believe yourself and believe in the patient. It will come across in your tone.

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