^^^At most health plans, the initial utilization review is done by a RN using a checklist or the trademarked Milliman UR protocols. It is usually not ever reviewed by a higher-level clinician unless the decision is appealed or it meets certain clinical criteria. I bet what happened here is that they looked at my most recent orthopedist visit back in February, noted the surgery was scheduled for early April, and denied since it was not yet three months. They did not review the notes going back for four years on the same problem.
