Using Evidence-Based Medicine to Appeal Medical Coverage Decisions [editorial]

Physicians are experiencing an increasing number of challenges regarding their medical judgment. Payment for services can be denied based on medical necessity or contractual exclusion of a service. Patients often call and ask for help because their prescription coverage was denied. I will present my approach to appealing coverage decisions. The approach has served my patients well over the years and involves 6 key messages: (1) understand the rules; (2) act professionally; (3) understand the process; (4) accept when the coverage decision is appropriate; (5) be persistent when the coverage decision is inappropriate; and (6) effectively use evidence-based medicine to help your patient.