Short answer: You can appeal almost any denial where your plan will not cover or pay for care you think should be covered, such as a service deemed “not medically necessary” or “experimental,” out-of-network care, an eligibility denial, or a cancellation of your coverage. Denials involving medical judgment or a rescission can also go to external review.
An internal appeal is available whenever your health plan will not provide or pay some or all of the cost of services you believe should be covered. Common reasons plans give include: the benefit is not offered, the care is “not medically necessary,” the treatment is “experimental” or “investigative,” you used an out-of-network provider, you are no longer eligible, or the insurer is rescinding your coverage for allegedly giving false or incomplete information.
Many of these can also proceed to an independent external review, including any denial that involves medical judgment where you or your provider may disagree with the plan, experimental-treatment determinations, and rescissions. If a denial is based on a factual or administrative error rather than medical judgment, the internal appeal is usually the place to correct it.