Letter

External review request

You exhausted your internal appeals and were still denied. An independent reviewer who does not work for your insurer decides, and the decision binds the plan.

Before you send this

Your final internal denial letter, sometimes called a final adverse determination
All prior appeal correspondence
Your state insurance department filing instructions, or the external review contact named in the denial
The filing deadline, which is often 4 months from the final denial

[DATE]

[STATE INSURANCE DEPARTMENT OR ASSIGNED INDEPENDENT REVIEW ORGANIZATION]

[ADDRESS]

Re: Request for independent external review

Patient name: [YOUR NAME]

Insurer: [INSURER NAME]

Member ID: [MEMBER ID]

Plan type: [employer plan / marketplace plan / individual plan]

Final internal denial dated: [DATE]

Service or drug denied: [ITEM]

To whom it may concern,

I am requesting independent external review of [INSURER NAME]'s final denial dated [DATE] for [ITEM]. I have completed my plan's internal appeals process.

Summary of the dispute:

I have insulin-dependent diabetes, diagnosed [YEAR]. My prescriber, [PRESCRIBER NAME], prescribed [ITEM] because [ONE SENTENCE OF CLINICAL REASON]. The plan denied coverage on the grounds that "[QUOTE THE DENIAL REASON]."

Why the denial should be overturned:

1. [Clinical point, tied to a document you are enclosing.]

2. [Second point.]

3. [Third point, if you have one.]

I authorize the release of my medical records relevant to this review to the independent review organization.

[If urgent:] I am requesting an expedited external review. Interruption of [ITEM] poses an immediate risk of diabetic ketoacidosis or severe hypoglycemia.

Enclosed:

- Final internal denial letter

- All prior appeal letters and plan responses

- Prescriber statement of medical necessity

- Relevant clinical records and lab results

- Signed authorization form, if required by the reviewer

Sincerely,

[YOUR NAME]

[PHONE]

[EMAIL]

[MAILING ADDRESS]

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