Example One:
One (covered) bone marrow transplant enabled a cancer-patient to go into remission. When the patient relapsed and the multiple myeloma recurred, the treating physician recommended a second and more controversial bone marrow transplant.

Was the second procedure experimental and therefore excluded or have advances in medical technology made this a standard and acceptable (and covered) course of treatment?

Example Two:
The plan participant sustained multiple, serious head injuries as a result of a motor vehicle accident. The patient was immediately admitted to intensive care (ICU) at the closest hospital. The patient remained in ICU for over a week. The Plan, based upon review by a managed care entity, denied the ICU-rate for all except the initial two days, saying the patient should have been moved to a regular hospital room after 48-hours.

Were all of the days in ICU medically necessary?

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Example Three:
Plan specifically excludes all “care and treatment of weight loss.” The treating physician says that a gastric-bypass procedure is medically necessary because the patient is morbidly obese.

Can the exclusion be upheld?

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Example Four:
The SPD specifically requires that all claims be submitted for payment “within 12 months of the date that the eligible expense was incurred.” Even if the procedure was a covered benefit...

Can this denial for untimely filing be enforced?

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Example Five:
A surgical-clinic split-billed for surgery in phases. Plan paid one (lesser) global fee.

Which fee is appropriate, according to the provider contract and currently accepted medical practice?

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