The structured process for challenging a refusal to cover treatment - internal appeal first, then in most cases an independent external review.
A denial is not a final answer. Health coverage in the United States is subject to a layered appeal structure, and a substantial share of denials are reversed when challenged. The first requirement is to identify what the denial actually says: a claim refused because a code was wrong, a referral was missing or the provider was out of network is a different problem from one refused as not medically necessary or as investigational, and only the second is really a coverage dispute.
The general shape is an internal appeal to the plan itself, followed - for most plans - by an external review by an independent organisation whose decision binds the plan. Federal law requires plans to give notice of an adverse determination that states the specific reason and the plan provision relied on, to provide free access on request to the documents and internal rules used to decide, and to offer an expedited route where waiting would seriously jeopardise health. State law adds its own external review systems for insured plans regulated by the state.
The single most consequential thing to know is that the internal appeal is where the record is built. For an employer-sponsored plan governed by ERISA, a court reviewing the decision later may be confined to the material that was before the plan when it decided, and may review a discretionary decision only for abuse of discretion rather than deciding the question afresh. Evidence not submitted during the internal appeal may simply never be considered. That is why the appeal should carry the treating clinician's reasoning in writing addressed to the plan's own stated criteria, the relevant records, and any applicable professional guidelines - not merely a request to reconsider.
Which rules apply depends on the plan type, and most people do not know their own. An individually purchased or fully insured employer plan is regulated by the state and by the federal Affordable Care Act appeal rules. A self-funded employer plan is governed by ERISA and generally not by state insurance law, including state external review. Government programmes have their own systems entirely - Medicare has a multi-level appeal ladder ending in federal court, Medicaid provides a fair hearing, and plans purchased through the marketplace have marketplace-specific routes. Separately, federal law now restricts surprise billing for many out-of-network emergency and facility-based services and provides its own dispute process, which is a different track from a coverage appeal.
Every stage of this runs on deadlines that are short and unforgiving, and they are set by the plan document, by regulation and by the programme involved. Read the denial letter for the specific periods that apply to you and diarise them the day it arrives; a right lost to a missed appeal period is very difficult to recover.
Do the internal appeal properly even if you intend to get help later, because for an employer plan it may be the only chance to put evidence on the record. Ask the plan in writing for the complete claim file, the specific criteria applied and the credentials of the reviewer - you are generally entitled to these free of charge, and a denial that cannot cite its own criterion is a weak one. Get your treating clinician to write to the stated criterion rather than in general terms, and ask about a peer-to-peer review. Where health is at immediate risk, ask explicitly for the expedited process. Free help exists: most states operate a consumer assistance programme or health insurance ombudsman, and hospital patient advocates and legal aid programmes handle denials routinely. A lawyer is worth engaging where the sum is large, where the treatment is urgent and the plan is unmoved, or where you are being told your plan is exempt from your state's external review.
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