A qualified, independent reviewer must decide the appeal
An appeal of a medical-judgment denial must be decided by a health professional with appropriate training and experience in the field, who was not involved in the original denial and is not their subordinate, and the plan must identify the medical experts it consulted. Asking who reviewed the claim is often the fastest way to find a defective decision.
When it applies
- Any denial based on medical judgment (medical necessity, experimental, level of care) on ERISA and ACA plans
- Peer-to-peer requests: you may ask for a reviewer of the same specialty
- Medicare Advantage reconsiderations, which must be made by a physician with expertise appropriate to the service when medical necessity is at issue (42 CFR 422.590)
Where it does not
- Purely administrative denials (eligibility, timely filing) that involve no medical judgment
The sentence to put in the appeal
“Please identify the name and specialty of the health care professional who made the initial determination and confirm that the appeal will be decided, as 29 CFR 2560.503-1(h)(3)(iii) and (v) require, by an appropriately qualified professional who neither made the original decision nor reports to the person who did, and disclose the identity of any medical expert consulted.”
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
Ask before the appeal is decided
Put the request in the appeal itself so the plan has to answer it in the decision.
- Step 2
Match the specialty
A rheumatology denial reviewed by a general practitioner is a fact worth stating plainly. Ask for a same-specialty reviewer and a peer-to-peer with the treating clinician.
- Step 3
Carry it to external review
External reviewers are clinicians in the relevant specialty. A plan that could not name one of its own is a weak opponent there.
Worked example
A spinal procedure was denied by a reviewer whose specialty the plan would not disclose. The appeal asked for the identity under the rule; the plan assigned an orthopaedic surgeon to the appeal and approved.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
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Sources
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