Insurance denied your claim as "not medically necessary"? You likely have federal external review rights most people never use — and the decision is binding on your insurer
If your insurer denied a claim on medical necessity grounds and your internal appeal failed, you can request independent external review under federal law. An Independent Review Organization — completely separate from your insurer — reviews your case. If they rule in your favor, your insurer has to cover it. That decision is legally binding. They can't appeal or overturn it.
This applies across treatment types: fertility, mental health, cancer drugs, surgery, specialist referrals. The process is the same.
A few things that trip people up:
It only works for medical necessity denials, not benefit exclusions. If your plan document flatly excludes a treatment, external review won't change that. But if your denial letter says "not medically necessary," "doesn't meet clinical criteria," or "experimental/investigational" — you have a real case.
Self-funded employer plans fall under ERISA (Employee Retirement Income Security Act) rather than state law, but federal external review protections still apply. A lot of people assume they have no rights because their state doesn't regulate their employer's plan. That assumption is wrong.
Your denial letter is legally required to include external review instructions. If yours doesn't, that's a compliance failure worth escalating on its own.
Deadlines are on your denial letter — check them. The federal floor is 180 days from your final internal denial to request external review, but some plans and states differ, and internal appeal windows are much shorter. The single biggest reason people lose this option is letting a deadline pass.
Standard external review takes up to 45 days. Urgent cases (where waiting causes serious harm) get an expedited 72-hour decision.
If you're dealing with a denial right now: drop the denial reason or the exact wording from your letter in the comments, and I'll tell you whether it looks like medical necessity (appealable) or a benefit exclusion (not), and what your deadline situation is. Happy to help people think it through.