Medical Letter of Necessity Denied

This is a discussion on Medical Letter of Necessity Denied within the Accidents and Injury Law Questions forums, part of the Legal Questions & Answers Forum category; I am currently in a no-fault case. I was referred for a procedure that was later denied by the no-fault carrier. The referring doctor is refusing to write a letter ...

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  1. #1
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    Medical Letter of Necessity Denied

    I am currently in a no-fault case. I was referred for a procedure that was later denied by the no-fault carrier. The referring doctor is refusing to write a letter of medical necessity.....isn't this doctor violating article 131 Line 35 and possibly 45. What recourse do I have with this doctor. I have no idea why they won't write me a letter so the ther doctor can appeal it and receive payment. I keep getting stonewalled by this referring doctors secretary I have not been able to talk with the referring doctor directly about this.


  2. #2
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    35. Ordering of excessive tests, treatment, or use of treatment
    facilities not warranted by the condition of the patient;
    His failing to say it was a an absolute necessity, does not negate its potential value in treating your condition. Payment for the procedure is between you and the insurance company.

    45. In the practice of ophthalmology, failing to provide a patient,
    upon request, with the patient's prescription including the name,
    address, and signature of the prescriber and the date of the
    prescription.
    This relates to a prescription for medication.

    http://www.health.ny.gov/regulations.../docs/131a.pdf

    Perhaps if you actually gave us information. instead of attempting to make us play 20 questions, you will get some good advice.

  3. #3
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    It would be a good idea to put all the communications between you and the doctor in writing, by certified mail, so that if it becomes necessary to make a case against the doctor that you would have proper documentation. Even an email would place some responsibility on the office for a response and show that you are communicating without response.

    With your overall goal here being to get your bill paid by the insurance company, or for you to get treatment which apparently the insurance company is trying to deny you. That said,

    Was this a car accident? Also, what state are you located in? Also, what kind of dollar amounts do these treatments run for? The reason I ask is that you may be able to attract the attention of a personal injury lawyer to help you in collecting from insurance. Have you already explored this at all?
    Legal Disclaimer: Answers to questions on this forum are for informational and educational purposes only and do not constitute Legal Advice. No attorney-client relationship is established through this forum.

  4. #4
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    it is in NY state. Also the test is about $2,000 it was a ENG. I already have a personal injury lawyer. The laywer's paper pusher told me I would have to get another lawyer for this denial of the procedure....because it is outside their scope. Personally I think that is a load of bull and would be more than happy to take my cash else where.

  5. #5
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    Sorry I meant 43 not 45.
    To me it does not make sense why this doctor is refusing to write the letter, they keep stating (through the secretary) that their notes are good enough. The doctor who I was referred to...doesnt understand it either. Why a doctor would not simply provide the evidence I need for an appeal or actually the other doctors office for their appeal. Is there any leverage I can apply to this doctor?

    Also I am in NY state if that helps.

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    This sounds like a very frustrating situation. I have heard of cases like this. As a moderator, I'll have someone shoot you some more information that hopefully should help you with this unwilling doctor!

  7. #7
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    All else fails, sometimes you can get a personal injury lawyer to have a look at your case and get a second look at it. Sometimes a personal injury lawyer might also have more information about reasonable amounts of money that you should have settled for on the case to begin with. You can have a look at the directory of personal injury lawyers in New York listed by city and you'll be able to talk to them both about the original medical claim or about the potential medical malpractice claim.
    Legal Disclaimer: Answers to questions on this forum are for informational and educational purposes only and do not constitute Legal Advice. No attorney-client relationship is established through this forum.


 

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