the external review thing finally clicked for me and I want to write it down
Posting this as a discussion rather than a claim: the external review thing finally clicked for me and I want to write it down. Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint. Internal appeals are…
Disagree with the tone strategy. Anger has never moved a determination; matching the criterion has.
Cosigning on external review. It is a real mechanism, it is underused, and the deadlines are strict.
Small fix — external review is independent of the plan. The second-level internal appeal is not.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
Step therapy requires documented trial of preferred alternatives. It is not an argument to be won on merits; it is a record to be produced, and the record is what the appeal must contain.