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External review

An independent, outside review of an insurer's denial after internal appeals are exhausted, with a decision the plan must follow.

By the glp1.how editorial teamReviewed

External review is the step after your insurer's internal appeal: an independent review organization, not the plan, looks at the denial and decides whether the medication should be covered. Under the Affordable Care Act, most plans must offer it for denials based on medical necessity or similar judgments, and the decision is binding on the insurer. Standard external reviews (external link) are decided within 45 days; an expedited review for urgent situations can be decided within 72 hours.

For GLP-1 denials, external review is where a well-documented case — diagnosis, BMI or comorbidity records, prior treatments tried, and a letter of medical necessity — gets a fresh set of eyes. Your denial notice should explain how to request it; see escalation paths beyond your insurer and my insurance denied coverage — what now?.

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Revision history

Updated 1 time since Sep 2, 2026 · show changes
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    Body revised

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Related terms

  • Medical necessity · The insurer's determination that a treatment is required to diagnose or treat a condition, often required for coverage approval.
  • Appeal · A formal request asking your insurer to reconsider a denied claim or prior authorization.
  • Letter of medical necessity · A prescriber's written statement explaining why a specific medication is medically required for a patient, used to support prior authorization and appeals.
  • Comorbidity · A health condition that exists alongside a primary condition, for example type 2 diabetes, high blood pressure, or sleep apnea occurring with obesity.
  • GLP-1 · A gut hormone (glucagon-like peptide-1) that stimulates insulin release, slows digestion, and reduces appetite; the target of drugs like semaglutide and liraglutide.
  • BMI · Body mass index: a weight-to-height ratio commonly used as a screening threshold for obesity and GLP-1 eligibility.

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