Step-by-step: Level 1, Level 2, and external review. What to say, what not to say, and how to frame your case.
A denial is often not a final decision. Many services are approved after additional documentation or a formal appeal. Understanding how the appeals process works helps you navigate it with less uncertainty.
| If the denial reason is... | The missing information is likely... |
|---|---|
| Incomplete documentation | Prior treatment history, functional impact statements, outside records, pharmacy history |
| Step therapy not met | Documentation of prior medications tried, duration, outcomes, and why they were stopped |
| Diagnosis mismatch | Relevant comorbidities or secondary diagnoses not included; incorrect ICD code submitted |
| Insufficient severity | Specific functional limitations not documented; general descriptions need specific examples |
| Administrative error | Incorrect insurance ID, missing forms, wrong payer, coding error — correct and resubmit |
| Not medically necessary | Clinical notes insufficient; peer-to-peer review may be most effective path |
| Option | Best Used When |
|---|---|
| Resubmit with additional documentation | Missing information has been identified and can be supplied quickly |
| Internal appeal | Clinical basis for denial is disputed or documentation is now available |
| Peer-to-peer review | Denial appears to be based on insufficient understanding of the clinical case |
| External review | Internal appeals have been exhausted and denial is believed to be incorrect |
| State/regulatory escalation | Insurer is not following required processes or consumer rights are at issue |
A peer-to-peer review is a direct conversation between your treating provider and a physician reviewer at the insurance company. It can be helpful but has important limitations.
It helps most when documentation is complete but clinical context is complex, when the reviewer may not have specialty expertise, or when the denial reason is medical necessity rather than missing information. Its limitations: the reviewer must still apply plan criteria — it is not a negotiation. Missing documentation cannot be supplied verbally during the call.
External review is conducted by an independent organization with no affiliation to your health plan. It is typically available after internal appeals are exhausted.
