• When an adverse benefit determination involves a medical condition of the claimant for which the timeframe for completion of an expedited internal appeal would seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function. 
   

• When a final internal adverse benefit determination involves a medical condition of the claimant for which the timeframe for completion of an expedited internal appeal would seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or 

• When a final internal adverse benefit determination concerns the admission, availability of care, continued stay or health care service for which the claimant received emergency services but has not yet been discharged from a facility. 

How to File an External Appeal 

1. Determine the Correct Audience: Before requesting an external appeal of a denial it is important to determine those to whom you need to direct the request. This is determined by your type of insurance.  

If you have health insurance through Medicare, Medicare Advantage (MA), Veteran’s Administration (VA), or Indian Health Services, federal regulators at The Department of Health and Human Services (HHS) have purview over your appeal.

2. Consider requesting an Expedited Review: Expedited external appeals are decided as soon as possible – no later than 72 hours, or less, depending on the medical urgency of the case, after the request was received. For people living with ALS, delays in care can have a substantial impact on quality and/or quantity of life, so in many cases an external appeal may be warranted. 

3. Gather Supporting Documentation: Obtain all relevant medical records and documentation from your healthcare provider that support the medical necessity of the request. This could include lab results, doctor’s notes, medical history, and test results. 

4. Letter from your doctor: Ask your healthcare provider to write a letter or provide an opinion explaining why the request is medically necessary. This can be crucial, especially if the denial is based on a lack of medical necessity. 

5. Relevant research or clinical guidelines: If the insurer denied a treatment based on the "experimental" or "investigational" label, providing clinical studies or guidelines supporting the effectiveness of the treatment can help strengthen your case. 

6. Write a Letter of Appeal: Draft a letter outlining your reasons for appealing the denial. Be clear about the facts of your case and refer to the evidence you are submitting. Include key details such as your full name, contact information, insurance ID number, the specific claim or service being denied, a detailed explanation of why you believe the claim should be approved (including the “four words”), citing medical evidence, guidelines, or policy language.  

7. Submit the Appeal According to the Agency’s Instructions: Follow the agency’s instructions for submitting the appeal and make sure you submit it within the required timeframe. Most give you four (4) months from the date of the denial. 

8. Keep Copies! Make sure to keep copies of everything you submit, including the appeal letter, supporting documents, and any forms. 

9. Follow Up: After submitting your appeal, confirm receipt with the agency. If possible, get a confirmation number or email. 

10. Stay organized: Keep a log of all communications, including dates of phone calls, emails, or letters. If you are following up, reference your appeal number or claim number. 

11. Review the decision: Once a decision has been made, determine whether another appeal is necessary. 

How to Appeal an Adverse External Appeal Decision

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