What Is an External Review and When Should I Request One?

When you qualify to request one

Federal rules put three kinds of denial in scope.

1. Medical judgment. Any denial that involves medical judgment where the enrollee or provider may disagree with the health plan can go to external review. Adverse benefit determinations involving medical judgment include those based on the plan's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit.

2. Experimental or investigational. Any denial that involves a determination that a treatment is experimental or investigational can go to external review.

3. Rescission. Cancellation of coverage based on the insurer's claim that the enrollee gave false or incomplete information on their application can go to external review.

You generally finish the plan's internal appeal first, with two exceptions. In urgent situations an enrollee may request an external review at the same time as the internal appeal, without having completed all of the health plan's internal appeals processes. Separately, an internal appeal is deemed exhausted when the plan or issuer waives the internal appeal, in urgent-care situations, or when the plan or issuer fails to comply with the internal appeals requirements.

If you have not filed the internal appeal yet, start there: how to appeal a GLP-1 insurance denial.

When external review may not be the right path

When a plan denies a claim it is required to notify the enrollee of the reason the claim was denied; read that stated reason before you file anything.

The three categories above are all decisions about you. A denial that says the plan does not cover weight-loss medication at all is about what the plan sells. A formulary is the list of prescription drugs covered by a prescription drug plan or other insurance plan offering prescription drug benefits, and a plan can be designed to leave a whole drug class off that list. The federal sources cited on this page do not state whether that kind of blanket exclusion is eligible for external review, so do not assume it is. Ask your plan in writing which review path applies to your specific denial code.

Two other routes exist for exclusion-type denials. A denial on the ground that the benefit is not offered under the enrollee's health plan can be appealed. And an enrollee has the right to follow their insurance company's drug exceptions process, which allows them to get a prescribed drug that is not normally covered by their health plan. To get a drug covered through the exceptions process the enrollee's doctor must confirm to the health plan, orally or in writing, that the drug is appropriate for the enrollee's medical condition — for example, that all other drugs covered by the plan have not been or will not be as effective as the drug being requested.

One more limit: the Affordable Care Act internal appeals and external review provisions apply only to health plans or policies created or purchased after March 23, 2010; grandfathered health plans are not covered.

For how plans structure GLP-1 coverage in the first place, see does insurance cover GLP-1 weight loss medication.

Deadlines and timelines

Under state external review minimum standards the claimant has five business days to submit additional information to the independent review organization, which has one business day to forward it to the plan or issuer.

Which process applies to your plan

Your letter tells you which of three tracks you are on.

If a state does not have an external review process that meets the minimum federal consumer protection standards, the U.S. Department of Health and Human Services oversees an external review process for health insurance companies in that state. If an enrollee's plan does not participate in a state or HHS-Administered Federal External Review Process, the health plan must contract with an independent review organization.

The HHS-Administered Federal External Review Process is administered by the designated federal contractor MAXIMUS Federal Services, Inc. The HHS-Administered Federal External Review Process is available at no cost to the health insurance plan, the consumer, or the consumer's authorized representative. After MAXIMUS receives an external review request it contacts the issuer, which must provide all documents related to the adverse benefit determination to MAXIMUS within five business days.

As of July 1, 2026, the HHS-Administered Federal External Review Process (FERP) is temporarily unavailable for enrollees who live in Alabama, Florida, Georgia, Texas, Wisconsin, or a U.S. territory other than Puerto Rico and whose plan or issuer uses that process; enrollees whose plan or issuer does not use the HHS-Administered FERP should follow the instructions in the notice from their plan or issuer. HHS states that the Federal Internal Claims and Appeals and External Review Team is working on a solution to the FERP outage and that HHS will provide more information about extending deadlines for eligible people requesting external review through the HHS-Administered FERP.

How to file

The Explanation of Benefits or the final denial of the internal appeal gives the contact information for the organization that will handle the enrollee's external review.

An enrollee may appoint a representative, such as their doctor or another medical professional who knows about their medical condition, to file an external review on their behalf.

On cost: the plan or issuer, not the enrollee, pays the independent review organization, and only states that expressly allowed a filing fee as of November 18, 2015 may still charge one — as of August 2026 HealthCare.gov states that the charge cannot be more than $25 per external review. Under the CMS process overview dated October 2025, a nominal state external review filing fee must not exceed $25, must be refunded if the adverse benefit determination is reversed, must be waived where payment would impose undue financial hardship, and the annual limit on filing fees for any claimant within a single plan year must not exceed $75. Also, a compliant state external review process may not impose a minimum dollar amount on a claim as a condition of external review.

HealthCare.gov's guidance is to keep the Explanation of Benefits forms or letters showing what payment or services were denied, a copy of the request for an internal appeal that was sent to the insurance company, and notes and dates from any phone conversations with the insurance company or doctor relating to the appeal. Keep their original documents and submit copies to the insurance company.

What a GLP-1 external review turns on

If your denial was medical necessity, the reviewer is comparing your record against the plan's own written rules — so get those rules first. A notice of adverse benefit determination must describe the internal guidelines or criterion used in making the determination and inform the consumer that a copy of the internal requirements will be provided free of charge upon request. If an adverse benefit determination is based on a medical necessity, experimental treatment, or similar exclusion, the notice must provide either an explanation of the scientific or clinical judgment for the determination or a notice that such an explanation will be provided free of charge upon request. Claimants may obtain coding and other information relevant to their claim for benefits free of charge upon request.

Then answer those criteria one at a time, in writing. An enrollee filing an internal appeal should submit any additional information they want the insurer to consider, such as a letter from the doctor.

After the decision

If you win, the plan has to act: if the external reviewer overturns the insurer's denial, the insurer must give the enrollee the payments or services requested in the claim. Decisions made by MAXIMUS under the HHS-Administered Federal External Review Process are final and binding on both the claimant and the health plan or issuer, except where other remedies are available under federal or state law, such as filing a lawsuit.

If you lose, there is still a place to go. A denial notice must inform the enrollee of the availability of a Consumer Assistance Program when the enrollee's state has one, and of a health insurance consumer assistance or ombudsman office. The Consumer Assistance Program in an enrollee's state can file an appeal on the enrollee's behalf.

Where Measured fits

Measured works at the front end of this process, not at the independent reviewer stage. Measured's insurance concierge team submits prior authorizations on the patient's behalf and keeps the patient updated on the insurance plan's determination, and Measured membership includes insurance benefit verification and prior authorization support, when applicable.

Timing matters: the internal appeal comes first, then a standard external review that can run up to 45 days. A cash-pay path can run in parallel. Measured lists Compounded Semaglutide as "No insurance required" with medication included in the membership price, from $119/mo as of August 2026. Compounded medications are not reviewed or approved by the FDA for safety or effectiveness. Measured membership fees are not covered by insurance and are paid separately.