Guide directory
Search for your denial type
These guides help you start. Your denial letter and plan-specific rules remain the primary source for your case.
9 types. Expand only the one you need.
Medications & prescriptionsGLP-1, biologics, cardiology, HIV, hep C, migraine, pain & moreShow guidesHide guides11 guidesShow guidesHide guides
- Open guide →
Cardiology drugs
Repatha denied 'step therapy not met' — 2022 ACC Expert Consensus + ezetimibe trial dates + FOURIER • Vyndamax denied 'AL amyloidosis not excluded' — PYP H/CL 1.7 + IFE/sFLC neg…
- Open guide →
Compounded GLP-1
'Compounded not covered — investigational / non-FDA-approved' — compounded drugs are NOT investigational; 21 USC §353a/§353b explicitly authorize practice-of-pharmacy products •…
- Open guide →
Compounded medications (non-GLP-1) — BHRT, LDN, ketamine, custom-dose pediatrics
UHC denial of BHRT cream — excipient allergy + USP 795 + DQSA §503A • Aetna denial of LDN for fibromyalgia — Younger PCRT 2013 + custom-dose 4.5 mg unavailable commercial • Cign…
- Open guide →
Diabetes drugs & insulin
Lantus denied 'try human NPH first' — DEVOTE NEJM 2017 + ADA §9.5 analog preference + documented hypo unawareness • Mounjaro denied 'try metformin first' — already on metformin…
- Open guide →
GLP-1 weight-loss drugs
Wegovy, Zepbound, Mounjaro, Ozempic, Saxenda
- Open guide →
Hepatitis C cures
Mavyret 8wk denied — 'try Harvoni first' (off-guidance step) • Epclusa denied — '6mo sobriety required' (B.E. v. Teeter) • Vosevi denied — 'try Mavyret again' (POLARIS-1) • DAA…
- Open guide →
HIV PrEP & HIV treatment
Cigna $60 copay on Descovy for PrEP — ACA §2713 + HHS FAQ Part 47 (July 2021) prohibit cost-sharing • UHC step-therapied Biktarvy through Dovato — patient is HBV+ (Dovato contra…
- Open guide →
Interventional pain — SCS, RFA, ESI, kyphoplasty
Aetna denial of HF10 SCS for PDN — SENZA-PDN RCT + FDA approval • Cigna denial of lumbar RFA — two MBBs >=80% + MPW 2020 • Anthem DRG denial for LE-CRPS — Budapest Criteria + AC…
- Open guide →
Migraine CGRP inhibitors
Aimovig denied citing CPB 0697 step therapy — we cite topiramate cognitive AEs + propranolol asthma contraindication • OptumRx denied Qulipta as 'not medically necessary' — we s…
- Open guide →
Severe acne
'Try OTC adapalene 0.1% first' — Aklief is selective RAR-gamma + PERFECT Br J Dermatol 2019 + truncal indication adapalene lacks • 'Try doxycycline 12 weeks before isotretinoin'…
- Open guide →
Specialty biologics
UHC denied Humira for biosimilar step therapy • Aetna required Otezla before Skyrizi • Cigna mandated TNFi before Rinvoq • ESI force-switched stable Humira to Cyltezo • BCBS den…
Cancer & oncologySolid tumors, blood cancers, CAR-T, transplants, pediatric oncologyShow guidesHide guides9 guidesShow guidesHide guides
- Open guide →
Adult CAR-T cell therapy
'Try auto-HSCT first' — ZUMA-7 NEJM 2022 + TRANSFORM Lancet 2022 established CAR-T as 2L for primary-refractory or early-relapse (<12 mo) DLBCL; auto-HSCT inappropriate for chem…
- Open guide →
Bone marrow transplant (allogeneic HSCT)
'Transplant denied — patient too old (age 65)' — RIC + non-MA conditioning extends eligibility to 75+; HCT-CI risk stratification (Sorror Blood 2005) drives selection, not chron…
- Open guide →
Cancer treatments
Keytruda denied for PD-L1 below threshold • Proton therapy 'experimental' for pediatric CNS • Enhertu denied for HER2-low breast • PET/CT for lymphoma restaging denied • Off-lab…
- Open guide →
Lymphoma & leukemia (heme malignancies)
'Step-therapy: must fail Imbruvica before Brukinsa' — ALPINE shows zanubrutinib superior PFS; ELEVATE-RR shows acalabrutinib non-inferior with significantly fewer cardiac events…
- Open guide →
Melanoma & melanoma-immunotherapy
'Combo Opdivo+Yervoy too toxic — try mono first' — CheckMate-067 6.5-yr update (Wolchok NEJM 2022): combo OS 49%, Opdivo 42%, Yervoy 23%; high-LDH/BRAF-mut/PD-L1-low benefit mos…
- Open guide →
Multiple myeloma (non-CAR-T)
'Bispecifics experimental — fail 5 prior lines first' — Tecvayli / Elrexfio / Talvey FDA-approved at ≥4 prior lines per FDA labels Oct 2022 / Aug 2023 / Aug 2023; NCCN MM v3.202…
- Open guide →
Pediatric oncology
'Out-of-network COG center not necessary' — pediatric cancer is rare, biologically distinct from adult; in-network adult facilities lack pediatric CAR-T REMS / FACT BMT / pediat…
- Open guide →
Prostate cancer
'Try generic ADT before ARSI in mHSPC' — STAMPEDE/LATITUDE/TITAN/ARCHES/ENZAMET established ARSI+ADT as standard mHSPC; doublet/triplet vs ADT alone improves OS • 'Pluvicto only…
- Open guide →
Radiation oncology — proton, SBRT, brachytherapy, IMRT, IORT
UHC denial of proton beam for skull-base chordoma — ASTRO Model Policy Group 1 + NCCN • Cigna denial of prostate SBRT — PACE-B + HYPO-RT-PC + ASTRO/ASCO/AUA 2018 update • Anthem…
Mental health & neurologyADHD, depression, anxiety, MS, epilepsy, eating disorders, SUD, TMS/ECTShow guidesHide guides11 guidesShow guidesHide guides
- Open guide →
Adult ADHD medications
Adderall denied for 'no childhood diagnosis' • Vyvanse 70mg dose cap • Step therapy to generic methylphenidate • Qelbree non-formulary • Shortage substitution refused
- Open guide →
Eating disorders — residential / PHP / IOP
Residential denied 'not medically unstable enough' — APA 2023 + AED 9th ed include behavioral severity + cognitive impairment + failed lower LOC, NOT just vital instability; med…
- Open guide →
Long COVID / PASC
'Self-limiting' denied — ICD-10 U09.9 effective Oct 1 2021 + WHO 2021 + Bowe/Al-Aly Nature Med 2022/2023 (2-yr persistence) • 'Graded exercise recommended' denied — patient has…
- Open guide →
Mental health & behavioral health
Inpatient stays, residential, PHP, IOP, therapy session caps, TMS, Spravato (esketamine), eating-disorder care, adolescent RTC, dual-diagnosis SUD
- Open guide →
MS treatments
Ocrevus denied for PPMS — even though it's the only FDA-approved option (ORATORIO) • Kesimpta blocked by step therapy through Tecfidera despite ASCLEPIOS proving superiority • T…
- Open guide →
Myasthenia gravis & CIDP
'Step-therapy: pyridostigmine + steroids + 1 IS before biologic' — IST 2020 + AAN 2021 refractory definition is inadequate response OR intolerance to ≥1 IS, OR chronic IVIG/PLEX…
- Open guide →
Neurology — Alzheimer's, Parkinson's, ALS, epilepsy
Leqembi denied 'experimental' — NCD 200.3 + CED registry + amyloid PET + ApoE4 + MRI plan • Kisunla denied 'tau too high' — TRAILBLAZER-ALZ 2 cohort data • Qalsody denied 'inves…
- Open guide →
Neuropsychological & psychological testing — ADHD, TBI, dementia, ASD, presurgical eval
UHC denial of comprehensive battery as 'duplicative' — 7-year gap + new TBI + NAN 2019 • Aetna ADHD eval denial requiring self-pay — AAP guideline + DIVA-5 documentation + funct…
- Open guide →
Pediatric epilepsy
'ACTH expensive — try prednisolone first' — AES 2010 update + 2024 update list ACTH as first-line; Lux UKISS Lancet 2004 supports hormonal therapy; relapse rates higher with pre…
- Open guide →
Substance use disorder treatment (SUD/MOUD)
Sublocade denied via step therapy — HOFER pivotal + diversion concerns + parity NQTL • Residential 3.5 denied as 'PHP sufficient' — ASAM 4e Dim 5/6 + state SB 855 GASC • Pregnan…
- Open guide →
Treatment-resistant depression — rTMS, Spravato, ECT
'TRD = >=4 failed antidepressants' — APA TRD 2022 + most insurance + STAR*D-DL: TRD = failure of >=2 adequate trials (different mechanisms or augmentation) • 'rTMS only after 4…
Autoimmune & inflammatoryPsoriasis, lupus, IBD, eczema, HAE, asthma & allergiesShow guidesHide guides7 guidesShow guidesHide guides
- Open guide →
Asthma & severe allergies
Xolair denied 'IgE outside dosing table' — submit Xolair PI dosing chart + EXTRA Ann Intern Med 2011; or for food allergy cite OUtMATCH NEJM 2024 + Feb 16 2024 approval • Dupixe…
- Open guide →
Atopic dermatitis (AD / eczema)
'Step-therapy through Dupixent first' — AAD 2024 + AAAAI 2023 list Adbry, Ebglyss, Cibinqo, Rinvoq, Nemluvio as PARALLEL options after topical/phototherapy failure, not sequenti…
- Open guide →
Hereditary angioedema (HAE)
'Prophylaxis not justified — only treat attacks on-demand' — WAO/EAACI 2021 + US HAEA 2020 abandon fixed attack-frequency threshold; LTP whenever disease activity / burden / con…
- Open guide →
Inflammatory bowel disease (Crohn's + UC)
'Step through Humira before Skyrizi' — AGA CD 2020 (Feuerstein) lists TNFi/IL-12-23/IL-23/anti-integrin/JAK as PARALLEL targeted options, not a mandated ladder • 'Try mesalamine…
- Open guide →
Lupus & rheumatology
'Step therapy: must fail MMF + cyclophosphamide before Benlysta or Lupkynis' — KDIGO 2024 + EULAR 2025 endorse EARLY combination therapy (MMF + belimumab OR MMF + CNI) for activ…
- Open guide →
Plaque psoriasis + psoriatic arthritis
'Step-therapy: must fail TNFi before IL-17/IL-23' — AAD-NPF 2019 (Menter) endorses TNFi, IL-17, IL-23, IL-12/23 as PARALLEL first-line systemic options after topical/phototherap…
- Open guide →
Thyroid eye disease (TED) — Tepezza (teprotumumab) and IGF-1R therapy
UHC denial of Tepezza for chronic-stable TED — OPTIC-X open-label + Ugradar Ophthalmology 2022 • Aetna denial citing 'CAS criterion not met' — Hertel measurement + diplopia + ph…
Cardiovascular & pulmonaryCardiac devices, pulmonary hypertension, COPD/AAT, cystic fibrosisShow guidesHide guides4 guidesShow guidesHide guides
- Open guide →
Cardiac devices & procedures
ICD denied 'GDMT not optimized' — NCD 20.4 + itemized GDMT log + SDM • TAVR denied 'low-risk experimental' — PARTNER 3/EVOLUT LR + 2023 VHD update + Heart Team note (two surgeon…
- Open guide →
COPD severe + alpha-1 antitrypsin deficiency
Dupixent COPD denied 'experimental' — FDA approved Sep 27, 2024 + BOREAS/NOTUS NEJM 2023/2024 + blood eos >=300 documented • Ohtuvayre denied 'try Trelegy first' — already on ma…
- Open guide →
Cystic fibrosis & pulmonary fibrosis
Trikafta denied — mutation isn't on label — CFF 2023 + CFTR2 theratype data • Step therapy says try Symdeko first — CFF 2023 first-line Trikafta recommendation • Ofev denied for…
- Open guide →
Pulmonary hypertension
'Step-therapy: PDE5 + ERA before prostacyclin' — ESC/ERS 2022 RECOMMENDS upfront double + risk-stratified triple for intermediate/high-risk; AMBITION proved upfront ambrisentan…
GI, liver, kidney & endocrineGERD, IBS, liver, kidney, CGM, thyroid, growth hormone, osteoporosisShow guidesHide guides11 guidesShow guidesHide guides
- Open guide →
Bariatric surgery — RYGB, sleeve, duodenal switch, SADI-S, revision, ESG
Aetna denial of RYGB on 'BMI 38' as below threshold — ASMBS 2022 (BMI >=35 + comorbidity or >=30 + metabolic) • UHC denial of sleeve→RYGB revision for GERD — LA grade C + DeMees…
- Open guide →
C. difficile infection
'Vancomycin first — fidaxomicin is brand-only / non-formulary' — IDSA/SHEA 2021 explicitly prefers fidaxomicin for BOTH initial and recurrent; OPT-80-003/-004 showed 14% absolut…
- Open guide →
Continuous glucose monitors & insulin pumps
UHC denied Dexcom G7 — 'not on enough insulin' • Aetna denied Omnipod 5 — 'closed-loop is experimental' • BCBS denied t:slim X2 replacement before 4-yr warranty • Cigna denied i…
- Open guide →
Endocrine (non-diabetes)
TRT denied — single T result — submit two AM measurements + Bhasin 2018 • Tepezza denied 'low CAS / inactive' — HORIZON + serial CAS exam + photos • Crenessity denied 'experimen…
- Open guide →
Eosinophilic esophagitis (EoE)
'Step-therapy: must fail 2 swallowed steroids before Dupixent' — ACG 2020 + AGA/JTF 2020 list these as PARALLEL options, no mandated sequence; LIBERTY-EoE-TREET enrolled steroid…
- Open guide →
GERD & severe reflux
Voquezna denied 'try esomeprazole first' — PHALCON-EE Laine Gastro 2023 LA-C/D superiority + CYP2C19 rapid metabolizer + Nov 1, 2023 approval • Dexilant denied 'duplicative of g…
- Open guide →
Growth hormone replacement therapy
'ISS is cosmetic — not medical' — FDA-approved indication since Jul 2003 for Humatrope (height SDS ≤-2.25, predicted adult ht >2 SD below MPH); Endocrine Society 2016 endorses I…
- Open guide →
IBS & functional GI
Xifaxan retreatment denied 'one course only' — TARGET-3 Lembo Gastro 2016 + FDA label permits up to 2 retreatments • Linzess denied 'try Miralax + senna first' — document ≥4 wk…
- Open guide →
Kidney disease — CKD, ESRD, IgAN, ADPKD
Tarpeyo denied 'RAASi not exhausted' — max-tolerated RAASi 9mo + persistent UPCR 1.4 + NefIgArd • Filspari for FSGS denied 'investigational' — Sept 2024 FDA expansion + DUPLEX •…
- Open guide →
Liver (non-HCV) — NASH/MASH, PBC, AIH, Wilson
Rezdiffra denied 'lifestyle first' — MAESTRO-NASH + AASLD 2023 + 8-month lifestyle attempt with 4% weight loss but persistent F3 • Iqirvo/Livdelzi denied 'try Ocaliva first' — O…
- Open guide →
Osteoporosis
Prolia denied 'try generic alendronate first' — ACP 2023 second-line denosumab + FREEDOM NEJM 2009 (68% vertebral / 40% hip reduction) + document esophageal disease / CrCl<35 /…
Rare & specialty conditionsAmyloidosis, sickle cell, hemophilia, SMA, IVIG, transplant, genetic testingShow guidesHide guides11 guidesShow guidesHide guides
- Open guide →
Amyloidosis (cardiac ATTR + AL)
'Tafamidis only Class IIa, not first-line' — ACC/AHA/HFSA 2022 explicitly recommends tafamidis Class IIa LOE B-R for NYHA I-III ATTR-CM; ATTR-ACT 30% mortality reduction NNT 7-9…
- Open guide →
Autoimmune cytopenias (ITP + AIHA)
'Step-therapy: must fail splenectomy before TPO-RA' — ASH 2019 explicitly lists TPO-RA as second-line BEFORE or INSTEAD of splenectomy • 'Tavalisse experimental' — FDA Apr 2018…
- Open guide →
Genetic testing
BRCA panel denied — patient meets NCCN BOP-2 (breast <=45) + USPSTF B-rec • FoundationOne CDx denied as 'experimental' — CMS NCD 90.2 + NCCN biomarker mandate • NIPT denied for…
- Open guide →
Hemophilia & bleeding disorders
Hemlibra denied as 'not necessary' for severe Hem A without inhibitors — HAVEN 3 + MASAC #258 • Roctavian denied as 'experimental' — FDA approval Jun 29, 2022 + GENEr8-1 • EHL E…
- Open guide →
Immune globulin (IVIG/SCIG) for PIDD
'Try fresh frozen plasma first' — FFP is not appropriate for chronic immune reconstitution; lacks standardized IgG dosing, infection risk, no functional vaccine antibodies • 'Ig…
- Open guide →
IV iron infusion
'Try oral iron first' — Tolkien PLoS One 2015 (>40% GI intolerance) + ACG 2020 + ECCO 2015 explicitly permit IV iron as first-line in malabsorption / IBD / ongoing loss / intole…
- Open guide →
Pediatric subspecialty — cardiology, GI, pulmonology, rheumatology, endocrinology, neurology
UHC denial of adalimumab for JIA — ACR 2019 + MTX failure + JADAS-10 + slit-lamp documentation • Aetna denial of dupilumab for peds EoE — NASPGHAN + >15 eos/HPF + PPI failure •…
- Open guide →
Rare disease — ERT, substrate reduction, gene therapy
Lumizyme denied as 'experimental' despite 2010 FDA approval — Orphan Drug Act rebuttal • Galafold denied for non-amenable variant — auto-checks Amicus FDA amenability list • Bri…
- Open guide →
Sickle cell & thalassemia
Casgevy denied 'experimental' — FDA Dec 2023 + CMS-CED + CLIMB-121 + ATC enrollment • Lyfgenia denied 'HU should be tried longer' — HU max-tolerated 35mg/kg with persistent VOCs…
- Open guide →
Solid-organ transplant
'Switch from Prograf to generic tacrolimus — therapeutically equivalent' — Tacrolimus is FDA-designated narrow-therapeutic-index (NTI) drug; ASN 2010 + 2018 statements + AST con…
- Open guide →
Spinal muscular atrophy
'Zolgensma age limit <2 yr' — FDA label is age <2 yr at administration; weight is dosing not eligibility (combination kits >=13.6 kg) • 'Combination Zolgensma + Spinraza/Evrysdi…
Women's, men's & reproductiveWomen's health, fertility, maternity, men's sexual healthShow guidesHide guides4 guidesShow guidesHide guides
- Open guide →
Fertility & IVF
IVF denied as 'not medically necessary' • Additional retrieval denied after one failed cycle • Egg freezing before chemo called 'experimental' • PGT-A 'investigational' • Same-s…
- Open guide →
Maternity & postpartum
'NIPT only covered if AMA >=35' — ACOG Bulletin 226 (2020) recommends offering cfDNA to ALL pregnancies regardless of maternal age + ACMG 2023 update + NEXT trial NEJM 2015 supe…
- Open guide →
Men's sexual health — TRT + ED
'Single low T doesn't qualify' — AUA 2018 + Endo Society 2018 require ≥2 separate AM total-T draws PLUS specific symptoms; if patient meets that, the criterion is met • 'TRT has…
- Open guide →
Women's health — menopause, endometriosis, PCOS, PPD
Veozah denied 'try paroxetine first' — SKYLIGHT-1/2 + NAMS 2023 hormone-therapy position statement + documented step-therapy failures or contraindications • Zurzuvae denied 'try…
Procedures, devices & rehabSurgery, orthopedics, stroke rehab, vision, dental, DME, sleep, hearingShow guidesHide guides22 guidesShow guidesHide guides
- Open guide →
BPH procedures + medical therapy
'UroLift only after medical-therapy failure' — LIFT enrolled both treatment-naïve AND refractory; AUA 2018 + 2023 lists UroLift as PARALLEL surgical option for prostate <80cc, N…
- Open guide →
Chronic wound care
'HBOT only for Wagner 3+ failed standard care 30 days' → cite CMS NCD 20.29 + SVS 2016 + Faglia Diabetes Care 1996 reduction in major amputation 8.6% vs 33.3% • 'NPWT 4-month ma…
- Open guide →
Dental — medical necessity, oral surgery, TMJ, cleft palate
TMJ arthrocentesis denied as 'dental' — CPB 0082 + DC/TMD + NAS 2020 TMD report • Pre-transplant dental capped — CY2023 CMS PFS rule + 42 CFR §411.15(i) • Cleft palate orthodont…
- Open guide →
DME — wheelchairs, prosthetics, orthotics
Group 3 PWC denied as 'Group 2 sufficient' for ALS patient • C-Leg microprocessor knee denied for K3 community ambulator • Full-electric hospital bed denied because 'patient amb…
- Open guide →
ENT / Otolaryngology — sinus surgery, septoplasty, tonsillectomy, head & neck
UHC denial of bilateral FESS for CRSwNP — Lund-Mackay 16 + AAO-HNS CRS 2015 update + 12 wks INCS failure • Cigna denial of septoplasty — NOSE 78 + CT-confirmed deviation + 4-mo…
- Open guide →
Glaucoma (drops + procedures + surgery)
'SLT not first-line / try drops first' — LiGHT (Gazzard Lancet 2019 + 6-yr Ophthalmology 2022) established SLT as preferred initial therapy; AAO POAG PPP 2020 lists SLT as first…
- Open guide →
Hearing aids, cochlear implants, BAHA
Pediatric BTE denied (IL commercial) — 215 ILCS 5/356z.10 mandate + JCIH 1-3-6 + IEP harm • Bilateral CI denied — expanded CMS NCD 50.3 + binaural evidence + AzBio 42% • Cochlea…
- Open guide →
Home healthcare — home nursing, home infusion, home PT/OT/SLP, home aide, hospital-at-home
UHC Medicare Advantage skilled home nursing denial — homebound + skilled task documentation + Manual Ch 7 • Aetna home IVIG denial — INS Standards + drug-class policy + safer at…
- Open guide →
Hospice / palliative — eligibility, GIP, recertification, concurrent care
Humana MA hospice eligibility denial for advanced dementia — FAST 7C + aspiration pneumonia + LCD L34538 • UHC GIP denial for terminal agitation — 42 CFR §418.302 + intractable…
- Open guide →
Inpatient rehab — IRF / SNF / LTAC admission and length-of-stay
UHC Medicare Advantage IRF denial after CVA — 60% Rule + 3 hr/day therapy tolerance + Section GG • Aetna SNF denial citing 'maintenance therapy' — Jimmo v. Sebelius + skilled se…
- Open guide →
Interventional radiology — UFE, PAE, TIPS, Y-90, tumor ablation, kyphoplasty
Aetna denial of UFE as 'investigational' — FIBROID Registry + EMMY trial + ACOG Practice Bulletin • UHC denial of PAE for BPH — UK-ROPE + PARTEM RCT + AUA support • Cigna denial…
- Open guide →
Mohs surgery & dermatologic surgery — BCC, SCC, melanoma in situ, SLNB, PDT
UHC denial of Mohs on nasal ala — AUC Area H + infiltrative subtype scoring 9/9 • Aetna denial of Mohs for trunk BCC — AUC mapping + recurrent tumor + immunosuppression • Cigna…
- Open guide →
Neurosurgery — discectomy, laminectomy, craniotomy, shunt
UHC denial of L5-S1 microdiscectomy — SPORT trial + cauda equina exclusion • Cigna denial of lumbar fusion (CCP 0051) — instability >=4mm + NASS Coverage Rec • Anthem denial of…
- Open guide →
Orthopedics & sports medicine
TKA denied 'BMI 41 — exceeds threshold' — AAOS 2023 BMI Position + Giori JBJS 2018 + document MBSAQIP weight optimization, GLP-1, HbA1c <7 • ACL denied 'try conservative first'…
- Open guide →
Out-of-network emergency
ER at OON hospital — NSA forces in-network cost-sharing • Surprise anesthesia bill — NSA prohibits, no waiver allowed • $70k air ambulance — NSA covers under §300gg-133 • OON gr…
- Open guide →
Pediatric therapy
ABA cut from 35 to 20 hrs/week — CASP 2020 + state mandate + MHPAEA NQTL parity • Speech denied as 'educational, not medical' — IDEA vs insurance distinction (Garret F.) • 'No l…
- Open guide →
Reconstructive plastic surgery — lymphedema, panniculectomy, burn, Mohs, hand
UHC denial of VLNT for ISL Stage II breast-cancer lymphedema — Becker LNT + ICG dermal backflow • Aetna denial of panniculectomy (CPB 0211) — Cohen criteria + chronic intertrigo…
- Open guide →
Sleep medicine — CPAP, BiPAP, ASV, oral appliances, Inspire HNS
CPAP denied for 'non-compliance' — 4hr/70%/30-day rebuttal with download data • Inspire denied as 'experimental' — FDA P130008 Apr 2014 + S090 June 2023 expansion to BMI 40 / AH…
- Open guide →
Stroke & neuro rehab
'tPA out of window — >4.5h post-onset' — DAWN NEJM 2018 + DEFUSE-3 NEJM 2018 — mechanical thrombectomy 6-24h with perfusion mismatch + AHA/ASA 2019 Class I LOE A • 'IRF admissio…
- Open guide →
Surgery denied as 'not medically necessary'
Bariatric denied for 'insufficient supervised diet' — ASMBS 2022 says obsolete • Lumbar fusion under Cigna CCP 0051 — we cite NASS + flexion-extension imaging • FFS denied as 'c…
- Open guide →
Vascular & endovascular — AAA, carotid, PAD, varicose veins, IVC filters
UHC denial of EVAR for 5.7cm AAA — SVS 2018 AAA + IFU compliance + Cook Zenith • Aetna denial of CAS as 'investigational' — CREST trial + SVS 2022 + symptomatic stenosis • Cigna…
- Open guide →
Vision & retinal — anti-VEGF, GA, gene therapy
Eylea/Vabysmo step-therapied through Avastin — Protocol T + prior Avastin failure with persistent SRF on OCT • Eylea HD denied 'no advantage over 2mg' — PULSAR/PHOTON non-inferi…