[Discussion] the external review advice in here is 2 years out of date
the external review advice in here is 2 years out of date, which sounds obvious until you try to state the evidence for it.
Since the title puts numbers in the shop window: 2 years.
Internal appeals are decided by the plan. External review is decided by an independent body and, where it applies, its determination is binding. They are separate mechanisms and the second is chronically underused.
Appeal deadlines run from the date on the determination letter. They are strict, they are short, and a missed deadline usually forfeits that level entirely.
Not medical advice, obviously, and nothing here is approved for human use. One person with a spreadsheet.
best — the order this archive was captured in
Prior authorisation criteria are republished each plan year. A criterion that blocked you in one year may not exist in the next, so a denial is worth retesting after the turnover.
The process that has actually worked for people on this board, in order.
Get the denial in writing and find the criterion it names. Request the clinical policy bulletin by its number. Write the appeal against that document, criterion by criterion, attaching what has been tried and for how long. Note the deadline from the letter date and diarise it.
If the first level fails, go to the second. If the second fails, ask about external review, which is independent and, where it applies, binding. Keep every date, department and reference number as you go.
It is administrative rather than rhetorical, and the people who win are the ones who treat it that way.
a template letter that quotes their own criteria back is the strongest one
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
That criterion is from the previous plan year. The current bulletin has different wording.
employer plans and individual plans are different fights
Why step therapy denials feel unfair and are nonetheless beatable.
The requirement is that documented trials of preferred alternatives exist. It is a record-keeping standard, not a clinical judgement about you, which is why arguing the clinical merits rarely moves it and producing dates and durations often does.
What to assemble: what was tried, at what dose, for how long, and what the documented outcome was. A one-page table with dates beats three pages of prose every time. Where a trial is contraindicated rather than simply unsuccessful, that needs to be stated explicitly by the prescriber in those terms.
None of this is legal or medical advice — it is what the threads here have found works.
Added a jurisdiction tag — the answers differ completely between countries and plan types.
A denial letter is required to state a reason and to reference the criterion applied. That reference is the handle: request the clinical policy document by its identifier and answer it point by point.
Asked for the policy bulletin by number and wrote the appeal against its criteria line by line. Approved on the second level after a flat first-level denial.
a peer-to-peer call is often faster than a written appeal
- 1employer plans and individual plans are different fights6 comments in this branch · started by u/prior_auth_pain