What types of disagreements qualify for external review?
Medical Necessity Most states allow you to appeal a denial of a claim when you have been told that the services are not “medically necessary.” Medical necessity generally means that the service or treatment is necessary and appropriate for the diagnosis or treatment of a covered illness or injury. Experimental/Investigational Most states also allow you to appeal a claim that was denied because the treatment or procedure is considered experimental or investigational. Dollar Value of Claims Usually there are no limits, but a few states require that your appeal involve a minimum amount of money (often between $100 and $500) to qualify for external review.
