Coverage appeal

When a plan denies coverage, you can ask it to look again. There are normally two stages.

Internal appeal. The plan reviews its own decision. You are entitled to ask for the specific reason for the denial and for the criteria the plan applied.

External review. If the internal appeal fails, an independent third party outside the plan reviews the case. The plan is bound by that outcome.

What tends to matter

Deadlines are real and they are shorter than people expect, so the date on the denial letter is the first thing to write down. Denials are also frequently administrative — a missing code, an unanswered criterion, a form submitted to the wrong department — rather than a judgement about whether the treatment suits you. That distinction is worth establishing early, because an administrative denial is often resolved by supplying one missing piece rather than by arguing the clinical case.

Where a delay would cause harm, ask about an expedited appeal.