Coverage Denial Authorization
A reviewer denies an inpatient claim on the basis of a coverage limit.
- Treating physician documentation present
- Prior authorization history present
- Clinical necessity assessment absent
- Comparable prior determinations two, both approved
- Specialist review record not located in supplied sources
A reviewer may deny on coverage grounds. The plan’s medical necessity policy requires a licensed clinician to review inpatient cases before denial.
Required clinician sign-off is absent from the supplied record, and the determination is inconsistent with two comparable prior matters.
The denial may have been correct. The contemporaneous record does not support the decision as made.
- Evidence completeness Limited
- Authority to deny on coverage grounds Strong
- Required clinician review before denial Insufficient
- Consistency with comparable prior matters Insufficient