Coverage Denial Authorization
A reviewer denies an inpatient claim on the basis of a coverage limit.
- Treating physician documentation present
- Prior authorization history present
- Licensed-clinician review record not in supplied record
- Clinical necessity assessment not in supplied record
- Comparable prior determinations (2) comparability not established
A reviewer may deny on coverage grounds. The plan’s medical necessity policy requires a licensed clinician to review inpatient cases before denial.
On the record supplied, IDALLOS cannot establish that the required licensed-clinician review occurred before denial, or that the determination is consistent with the two comparable prior determinations.
The denial may have been correct. On the contemporaneous record supplied, IDALLOS cannot establish that it was supported as made.
- Evidence completeness Limited
- Authority to deny on coverage grounds Strong
- Required clinician review before denial Insufficient
- Consistency with comparable prior determinations Insufficient