in america, when a child on medicaid needs care,
someone first writes a letter saying no.

DENIED

Empire State Family Health Plan notice of adverse benefit determination

Member: J.O., age 8 · Requested: biologic therapy for severe asthma

Determination: denied. The clinical information submitted does not meet plan guideline A-0412. plan guidelines are not the law. federal law — EPSDT, 42 U.S.C. § 1396d(r) — entitles every child on Medicaid to medically necessary care. the guideline yields.

Criteria require two exacerbations within twelve months; records document one. the second exacerbation exists — an urgent-care record the plan never requested. denials are often built on the absence of a document, not the absence of a fact.

The requested service is therefore not medically necessary. his pulmonologist says otherwise. under EPSDT, her judgment — not an actuarial threshold — is the standard for an 8-year-old.

guideline, 3 claims · law, 0 answers

a denial is not a verdict.
it is an argument — and arguments can be answered.

families who appeal pediatric Medicaid denials with complete records win the overwhelming majority of the time. almost no one appeals.

verteryx

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we read every line of the no,
and answer it with the law.

read the research →