Every state has one. Most people have never heard of it. It is free, it is binding on your insurer, and it reverses denials in a significant percentage of cases.
An Independent Medical Review is a review of your insurer's denial by a licensed physician who has no financial relationship with your insurance company. The reviewer is selected from a pool of certified Independent Review Organizations (IROs) accredited by state regulators or CMS.
The reviewer looks at your medical records, your doctor's documentation, your insurer's denial rationale, and the applicable coverage and clinical criteria. They issue a binding determination. If they overturn your insurer's denial, your insurer must cover the service — period. They do not get to appeal the external reviewer's decision.
A 2023 KFF survey found that only 40% of consumers know they have the legal right to appeal to an independent medical expert. More than half were unsure, and 9% believed they had no appeal rights at all.
States with mandatory reporting show overturn rates ranging from 20% to over 40% depending on the category of denial. For experimental or investigational denials and mental health parity denials, overturn rates tend to be higher. Even a 20% overturn rate on a process that takes one phone call and no money is worth attempting.
