Let’s say a family member, a child, a parent, or a spouse is critically ill. You have consulted with the best doctors in Los Angeles. Your loved one is on a list for liver transplant. And you wait: six months, a year, and six months more. You wait, and wait until you are losing faith in the medical system altogether.

At the time your family member is added to the list of waiting, you are told that if there is cancer, and the MRI* suggests as much, there will come a time when the patient will not be eligible for transplant.

“Sorry. That’s Life.” This is the thrust of initial evaluation by the experts on the transplant team.

So, you try to learn everything there is to know about organ transplant, and fall forward into the black hole of medical data of which there is no alpha, and certainly no omega.

Upon learning that the country is chopped into organ donation regions, you discover there may be other options.

The United Network for Organ Sharing was first awarded the Organ Procurement and Transplant Network contract in 1986 to create and run a private and non-profit organization. This is confirmed by their website.

It looks like from the data provided by these organizations, that, leaving town may offer a better chance of transplant and survival.

So based on research in the Scientific Registry of Transplant Recipients another hospital transplant more patients and has a shorter wait list. It will not be easy, but you decide to pack up and go. Insurance has been approved at your current hospital, what would prevent stop you from going elsewhere?

As it turns out, maybe your Insurance Company.

Here are a Decision Letter Notes.

“After a complete review of this request, the insurer’s Medical Director denied coverage for repeat evaluation for transplant. Your plan covers services that are medically necessary as determined by your insurer to be no more than the basic health needs of the patient:

The testing proposed by the additional medical facility is consistent with Zone 1 evaluation for transplant, and the proposed repeat evaluation is more than required to meet your basic health needs, and therefore does not meet the criteria as medically necessary for your condition and is excluded from benefit coverage.”

The cost controllers who in the case of your Insurer are doctors, have contacted your existing medical team and write in their report that you’re better off staying put in your home state.

So here you have your insurer making life and death decisions on your behalf with what sounds like on the surface your best interests in mind. You must feel so much better. The decision to approve or deny any procedure goes back to cost. How much money is involved? If it is a lot of money and certainly liver transplant is, you may rest assured any reason to derail a move to another facility will be considered.

Now what?

The Insurance Company has advised you that you may appeal. Then do it.

Make as loud a noise, create as much of a bureaucratic nightmare as you possibly can. Be passionate.

Expedited appeals are typically available in life threatening issues with a response from a different M.D. than the one first ruling on case coverage.

Take time to write as compelling an argument as possible. Quote bona fide source that helps your case.

You do not have to be the smartest guy in the room to overturn a Doctor. It can be done, and was in the case referred to here.