Health Insurance Denials: The External Review Lifeline- Medicare, Medicaid, and MA Users Tools

Receiving a denial letter from your health insurer can feel like a gut punch, especially when it blocks treatment for a chronic condition or urgent need. But there's a powerful, often underused tool called an external review that can overturn those decisions through an independent, binding process. A recent ProPublica investigation (October 2025) spotlights this appeal mechanism, detailing how it forced a major insurer to cover $70,000 in psychiatric care after repeated rejections. The article focuses on private plans under the Affordable Care Act (ACA), but for seniors and families navigating aging in place, understanding its scope and alternatives for Medicare, Medicaid, Medicare Advantage (MA), and Medigap is crucial. 
As we've emphasized on this Blog, proactive tools and planning can prevent denials from escalating to crises, but knowing your appeal rights is your first line of defense. This article explains external reviews plainly, assesses their applicability to government programs, and outlines similar options to keep care flowing at home, empowering you to fight back without the stress of starting from scratch.What Is an External Review? A Step-by-Step Lifeline for Denied Claims
An external review is like calling in an impartial referee when your insurer says "no" to a claim. After an internal appeal fails (where the insurer reviews its own decision), you request an independent third party, often a doctor or specialist, to evaluate the denial. If they rule in your favor, the insurer must pay, and it's binding. The ProPublica piece illustrates this with Teressa Sutton-Schulman's story: Her husband's insurer, Highmark Blue Cross Blue Shield, denied more than $70,000 in mental health treatment after suicide attempts. After internal appeals failed, an external reviewer (Dr. Neal Goldenberg) overturned it, citing medical necessity, saving lives and money.
The process is straightforward but time-sensitive:

1. File Internal Appeal: Within 180 days of denial (most plans require this first).
2. Request External Review: Submit to your state's insurance department or the plan (often within 4 months); include medical records and a doctor's letter.
3. Independent Review: Takes 45-60 days (72 hours for urgent cases); the reviewer has no insurer ties.
4. Outcome: Approval means immediate coverage; denial allows further appeals or lawsuits.

Under the ACA, it's free or low-cost ($0-25 fee in some states), and state programs like Connecticut's Office of the Healthcare Advocate overturn 80% of cases. But it's not a cure-all; ineligible are routine denials (e.g., out-of-network) or non-medical judgments.External Review Does Not Apply to Medicare, Medicaid, MA, or Medicare Supplements, BUT  Alternatives Exist
Unfortunately, the ACA's external review process, detailed in ProPublica, does not directly apply to government programs like Medicare, Medicaid, Medicare Advantage (MA), or Medigap supplements. These have their own built-in appeals systems, tailored to federal/state rules, without a universal "external" step. Here's the breakdown:

• Original Medicare (Parts A & B): No external review; instead, use the five-level appeal process through your Medicare Administrative Contractor (MAC). Start with a redetermination (within 120 days of denial), escalate to reconsideration, ALJ hearing, Medicare Appeals Council, and federal court. It's free or low cost, and many Part A claims are overturned at higher levels . For home health denials, this ensures access to aides for aging in place.
• Medicaid: Varies by state but typically includes fair hearings through your state's Medicaid agency (within 90 days of denial). No formal external review, but states must offer independent medical reviews for certain disputes. In Missouri or Ohio, contact your state's Department of Health for a hearing. 
• Medicare Advantage (MA): Follows the Medicare five-level appeals for covered services, but MA plans must offer a fast-track process for urgent denials (within 72 hours). No external review, but if denied, escalate to the Independent Review Entity (IRE) for Part C plans MA's appeal rights mirror Original Medicare but with plan-specific twists.
• Medigap Supplements: These don't have denials (they pay fixed amounts after Medicare), so no appeals process. Issues arise if Medicare denies first; appeal that via the five-level system.

The gap? Without ACA's independent reviewer, government appeals feel more bureaucratic, with success hinging on documentation. ProPublica's focus was on private plans.  Compared to ACA's protections, seniors on public programs are underserved, but alternatives provide similar recourse.Similar Options If External Review Doesn't Apply: Your Appeals Arsenal
The good news? Each program has robust, no-cost appeals, think of them as "internal externals" with escalation paths. Here's how to navigate:

1. Medicare's Five-Level Ladder:
   • Level 1 (Redetermination): File with your MAC within 120 days—65% success for simple denials (e.g., home health hours).
   • Level 2-5: Escalate to QIC, ALJ, Council, or court; free legal aid via Medicare Rights Center (1-888-696-7213). Illustration: A denied wheelchair? Level 1 often overturns it with a doctor's note.
   • Tip: Use the Medicare.gov appeals tool;  escalated claims routinely win.
2. Medicaid Fair Hearings:
   • Request a hearing within 90 days via your state agency; impartial hearing officers review, with significant overturn rates. For home care denials, submit medical evidence.
   • Example: Ohio's PASSPORT waiver denial? Appeal via Ohio Department of Medicaid Administrative Services (ODMAS), often resolved based on family testimony.
   • Tip: Contact your state's Long-Term Care Ombudsman for free advocacy in institutional care.
3. MA Plan Appeals:
   • Fast Appeal: Within 72 hours for urgent needs (e.g., home oxygen); plans must continue coverage during review.
   • Standard: 60 days for non-urgent; escalate to IRE if denied.
   • Illustration: MA denies PT sessions? Fast appeal keeps them going while reviewed, success is higher with a doctor's letter.
   • Tip: Use the MA plan's member services; 1-800-MEDICARE for complaints.
4. Medigap: Appeal Medicare denials first, as supplements follow suit. Unfortunately, there is no direct process; contact your insurer for assistance.
5. Consumer Assistance Programs (CAPs): Many states, including Ohio and Missouri, offer help to consumers with health insurance problems through Consumer Assistance Programs (CAPs). State CAPs offer direct assistance by phone, direct mail, email, or walk-in locations to help consumers learn how to obtain or use their insurance effectively. CAPs play a critical role in ensuring that consumers are able to find health insurance and are able to access the benefits to which they are entitled. 
6. Nononprofits:  The Center for Medicare Advocacy,  or Justice in Aging offer free help, overturning cases with guidance. ProPublica's Connecticut example shows state advocates resolving cases. 

Conclusion: Your Right to Fight Back
External reviews empower private plan users, but Medicare/Medicaid's appeals offer similar free, structured paths to coverage. While this article has provided a thorough overview of denial appeals and alternatives, it is by no means comprehensive. The landscape evolves rapidly, influenced by ACA and CMS rules. Readers must remain vigilant, consulting Medicare.gov, state agencies, and elder law attorneys to evaluate their situations and identify risks. By combining awareness with proactive planning, seniors and families can better safeguard independence and thrive as they age in place.