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External Review vs Independent Review: Are They Different for Insurance Appeals?

When you are appealing an insurance coverage denial, there can be a big difference between an “external review” and an “independent review.”

Why is the difference so important? Many times a bariatric surgery appeal is sent by your insurance plan to an “external peer reviewer” who often comes back with another denial. Then your insurance company writes you or your surgeon a letter saying, “this matter was reviewed by an external peer specialist with expertise in bariatric medicine…” or something similar.

Don’t let the word “external” fool you! This “external” peer reviewer is chosen by the insurer as part of its internal appeal process, so you can imagine whose side that “external” reviewer is on.

If this “external” reviewer upholds the insurance company’s denial, patients or their doctors often just give up, mistakenly thinking that the external review is the final word on the subject and they have no other options. That’s not true.

If your bariatric surgery has been denied by the insurance company, then denied again by an “external reviewer,” make sure you get your appeal reviewed by an Independent Review Organization (IRO), which is not controlled by the insurance company or bound by the insurer’s rules and medical policy. An IRO offers a truly independent decision, and gives the patient the best chance of getting coverage for bariatric surgery approved.