I can't answer your question. I tried to get my first llmd covered, because he was part of the group but in another state. That was the reason for denial. I was just to sick to fight.

What I did discover was that the lab work and drugs were covered when ordered by the llmd. So paying for the llmd isn't too bad because everything else is covered. I hope your HMO works that way too.
 

First of all, lyme is a clinical diagnosis, testing doesn't matter. How do we know this ? Just follow the link below because the HHS says so. Oh and by the way, they also talk about the seriousness of chronic lyme, so I would think a "Specialist" is in order. Does your insurance company really want to run afoul of the Health & Human Services criteria ?
http://www.hhs.gov/asl/testify/t040129.html

 

But, every time we've won an appeal or gotten reimbursed for a claim, documentation of all sorts played a huge role.

You might have the best of both worlds if you do the over-the-phone thing, but send them all the documentation you would for a written appeal (as in, all the studies that support your point of view, plus blood work, plus supportive info from the doctor's notes, etc. Overkill is good.), plus a list of talking points. Then, after the discussion, send them a summary of what you talked about and any info to resolve any of the areas they are squirrelly on.

I think the big question is -- what is the appeal process for each of these routes? Is the "complaint resolution" supposed to be more final than the written grievance?

It helps to remember that the intent of the company is usually to screen you OUT of getting care, not to have a reasonable exchange of information and an honest assessment of appropriate treatment. There are exceptions and we've come across a few consciencious, helpful, and honorable claims reps, but we've also encountered astonishing levels of either outright dishonesty or phenonenal determination to disregard every scrap of (the very solid) evidence that we had.
 

Best of luck.