What to expect from an external review decision

After you request external review, an independent reviewer reads your records and decides whether the plan’s denial should stand. A standard decision is due within 45 days after the reviewer receives your request, and an expedited decision within 72 hours at most. If the reviewer overturns the denial, the plan has to provide coverage or payment immediately. If the reviewer upholds it, you still have options, which are covered in the last section.

What this means

The reviewer looks at the case fresh. It is not bound by the plan’s earlier decisions, and it considers the medical records, your treating professional’s recommendation, the plan’s terms and evidence-based practice guidelines. If the plan does not send its file within 5 business days, the reviewer under the federal process may end the review and reverse the denial.

The decision is binding on both sides. Neither you nor the plan can simply ignore it. The rule also says it binds “except to the extent other remedies are available under State or Federal law”, so a court may still be an option in some cases. The notice of the decision must say that judicial review may be available. That is a statement of possibility, not a promise.

No national official figure for how often external reviewers overturn denials was found. One state publishes its own figures: California’s Department of Managed Health Care reports that, of 3,290 medical-necessity reviews in 2025, 57.39% were overturned by the reviewer, 23.01% were reversed by the plan itself and 19.60% were upheld. That is one state’s regulated plans in one year, not a national rate and not a forecast for your case.

What to do

1. Mark the decision date. Count 45 days from the day the reviewer received your request for a standard review, or 72 hours for an expedited one. The decision clock can do the counting.
2. Ask for a written copy if you only heard by phone. If the first notice of an expedited decision was not in writing, written confirmation must follow within 48 hours.
3. Read the decision notice in full. Find the outcome, the reasons and what it says about your next options. Save every page.
4. If you won, check that the plan acts. Ask the plan, in writing, to confirm when coverage will start or payment will be made. Keep the date of your request.
5. If the plan does not act, tell the regulator. For an insured plan, that is your state insurance department. For a private employer plan, it is the Department of Labor. See how to file a complaint with your state insurance department and how to get help from the Department of Labor.
6. If you lost, read the notice for what the reviewer found missing. The weakness named in the reasons shows what new evidence might help.
7. Hold on to every record. A later request, complaint or lawsuit will use them.

What the plan may say, and what to say back

“We are still deciding whether to implement the decision.” The plan must provide coverage or payment immediately and without delay, even if it intends to seek court review. Put your request in writing and send it to the plan’s appeals address.

“The reviewer upheld our decision, so there is nothing more we can do.” The decision binds the parties, but other remedies under state or federal law may remain. Ask the plan in writing to confirm that the denial is final, and look at after a final denial.

“You owe the full bill.” If the reviewer overturned the denial, tell the provider and the plan. Ask for a corrected explanation of benefits. See the bill while you appeal.

The rule

The external review decision binds the plan or insurer and the claimant “except to the extent other remedies are available under State or Federal law”. If the final external review decision reverses the denial, the plan must provide coverage or payment immediately and without delay, even if it intends to seek court review. See title 29 of the Code of Federal Regulations (CFR), section 2590.715-2719(c)(2)(xi) and (d)(2)(iv).

Watch for

• A decision that was not written. Ask for the written notice. You need the reasons.
• Unclear wording. If you cannot tell who won, ask the plan and the reviewer’s office to say it plainly in writing.
• Time. A decision on a standard review can take up to 45 days. If your case is urgent, ask for expedited review at the start, not later.
• No second external review. We found no federal rule describing a second external review for the same denial. A new request with new evidence is a separate question, covered in after a final denial.

What to do if the reviewer upholds the denial

You have options, though none is a promise. You can ask your employer to look at the case if the plan is self-funded. You can complain to the regulator. You can look at a lawsuit, with a lawyer’s help and with attention to any time limit in your plan document. You can also deal with the bill by seeking financial assistance and negotiating. See after a final denial: every option left.

What next

• After a final denial: every option left: the honest list of what remains.
• Asking your employer to overrule a denial: for self-funded job-based plans.
• Suing your health plan: what the law says, and why to speak to a lawyer first.