External review: a free, binding second opinion
After the plan's final internal denial, you can ask an independent review organisation to decide medical-necessity, appropriateness, setting, level-of-care, effectiveness and experimental determinations, at no meaningful cost, and its decision binds the plan. It is the step most denied patients never take.
When it applies
- ERISA and ACA plans after the internal appeal (or alongside it in urgent cases)
- Self-funded plans through the federal process or a contracted IRO
- Denials involving medical judgment; rescissions of coverage
Where it does not
- Pure eligibility or contractual exclusions with no medical judgment (those go to the regulator or court)
- Original Medicare and Medicaid, which use their own ladders
The sentence to put in the appeal
“Having received the final internal adverse benefit determination dated [date], I request external review under 45 CFR 147.136(d) [and 29 CFR 2560.503-1 / the plan's federal external review process]. The determination involves medical judgment [medical necessity / experimental] and is within the scope of external review. Enclosed are the denial, the criteria relied on, the treating clinician's letter and the records.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Find the right process
State-regulated plans: the regulator named on the letter. Self-funded plans: the federal process or the IRO the plan contracts. The letter must tell you which.
- Step 2
Send a complete record
The reviewer decides on paper. Include everything the plan saw and everything it should have.
- Step 3
Ask for expedited review when urgent
72 hours where a delay would jeopardise health; standard decisions within 45 days.
Worked example
A proton-therapy denial upheld internally as experimental was sent to external review with the treating oncologist's letter and the guideline citations; the IRO reversed within three weeks.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
Go deeper
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours, tells you in writing which rules apply and whether it can be appealed, and Apellica prepares the appeal with the citations. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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