Not So Fast!

See what Not So Fast! gives you

Real output from an actual run on the situation below. Most of the result is shown; nothing is reworded.

The situation

Health insurance. Denied claim for procedure my doctor says was medically necessary. Already appealed once and got denied again.

Real run, 2026-10-07 — one of the tool's own built-in examples.

Why this happened

Two-level denials often reflect a review process that is checklist-driven at both stages, not a final judgment by someone with full clinical discretion.

Common reasons for a denial like this

• The procedure code used does not match the insurer's criteria for the listed diagnosis code
• The clinical documentation submitted did not explicitly address the insurer's specific medical necessity criteria language
• The reviewing clinician at the appeals stage was not a specialist in the relevant field
• The insurer's coverage policy excludes the specific procedure variant billed, even if a related procedure is covered
• A required prior authorization step was missing or retroactively contested

Where the power is

The insurer's Medical Director (or Associate Medical Director for the relevant specialty) is the first internal actor with documented authority to grant an exception; above that, an external Independent Review Organization assigned by your state regulator has binding authority the insurer cannot override.

The escalation ladder

• 1. Request Peer-to-Peer Review with Medical Director: Have your treating physician call the insurer's provider line and request a peer-to-peer clinical review with the Medical Director or a specialist reviewer in the relevant field — not a general appeals rep.
• 2. Request External Independent Medical Review: File a formal request for External Review (also called Independent Review) through your state insurance department or directly with the insurer, who is required to provide this option after two internal denials.
• 3. File a Complaint with Your State Insurance Department: Submit a written complaint to your state's insurance regulatory department, attaching both denial letters, your doctor's medical necessity letter, and your external review request if filed.
• 4. Employer Benefits Administrator (if employer-sponsored plan): If your insurance is through an employer, contact your HR or benefits department and request that they escalate the denial through their account representative at the insurer.

A route most people miss

• Expedited External Review for urgent or ongoing medical situations: Ask the insurer in writing for expedited external review and have your doctor document that delay poses a health risk — most states require a decision within 72 hours under expedited rules.

Words that route your request differently

• “I am requesting the name and specialty of the physician who reviewed my appeal” — when speaking with the insurer after the second denial.
• “Please provide the specific clinical criteria used to determine that this procedure does not meet medical necessity” — in any written communication requesting the denial rationale.
• “I am formally requesting external independent review as provided under my plan and applicable state law” — in the written request you send after the second internal denial.

Honest assessment: medium chance

A well-documented peer-to-peer review combined with a formal external review request gives a genuine path to reversal, particularly if the treating physician can directly address the insurer's stated criteria — success is possible but not certain.

The first move

Call your doctor's office today and ask them to request a peer-to-peer review with the insurer's Medical Director, while you simultaneously request the specific clinical criteria used to deny the claim in writing.

General information, not legal advice. Appeal rights and deadlines depend on your state and on whether your plan is insured or self-funded — your denial letter says which rules apply.