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Perhaps this family did not appeal the original denial and instead jumped on the Michael Moore bandwagon threatening bad press.

Then again, it's entirely possible that the original appeal was received by a health information technician who has been told repeatedly that his/her next pay raise is dependent on how many appeals they receive and deny, and rather than applying the criteria correctly, they simply rubber-stamped it and returned it. Not that it ever happens.

This is going to make life...interesting. We deal with denials every day. Real life situation - grandpa (not mine) is eighty-four years old, and has been taking Aricept for the past three years. On his last MMSE, he lost points, and no longer meets criteria for the medication, so prior authorization is denied. The medication is no longer doing him any good. When the family appeals what is obviously a losing situation - does the plan give in and continue to pay for the medication or stand firm on the denial?

Or the one I got to deal with. Seventy-five year old patient with cancer. MD wants him to try a new oral chemotherapy medication. Plan denies it, and advises that in order to authorize the medication, the patient needs to try and fail two types of platinum based chemotherapy. The denial is not based upon any kind of criteria coming from the medications manufacturer, but is based upon criteria made up by the Prior Authorization medical team. They don't look at the facts of the case - if those two treatments fail (which they will, based upon the oncologists evaluation), then the patient will not have time to respond to the denied medication, the patient has had twelve mini-strokes and the required chemo is likely to induce more, or the fact that the patient has had multiple surgeries to treat the cancer and it's simply getting more aggressive. They just look at prior medication history and say "no."

Sorry about the mini-rant - I'm going to have to write more about this.