What it means
If your plan still denies coverage after an internal appeal, you can usually ask for an external review. An independent reviewer looks at the medical records and the plan's rules and decides whether the denial should stand.
HealthCare.gov says you must file a written request within 4 months of receiving the insurer's final denial. Standard reviews are decided within 45 days, and expedited reviews for urgent situations within 72 hours or less. In urgent cases you may be able to request external review before finishing the internal appeals.
For plans covered by these federal rules, the insurer must accept the reviewer's decision. Some states run their own external review programs, and self-funded employer plans may follow a federal process instead.
Keep copies of every letter, note the dates and ask your prescriber for a letter of medical necessity that cites the plan's own criteria.
Why it matters
External review is the last step most people have when a plan refuses to cover a GLP-1 they meet criteria for.