Who reviewed your denial, and what to look up

How to ask, and what to check

1. Ask for the reviewer, in writing Request the name, professional credentials, board certification and specialty of every person who reviewed the claim, along with the clinical rationale and any guideline they applied. Send it as a document request, not a question in a phone call.
2. Compare their specialty to your procedure A reviewer whose specialty has nothing to do with the surgery being denied is a fair thing to raise. So is a plan that will not say. Neither of these wins on its own; both change what the plan has to explain.
3. Look up what they actually do Providers have a public national identifier, and federal billing data shows which procedures they have actually performed. Someone whose practice is entirely office visits is in a different position when judging a complex surgical technique.
4. Check for industry payments Payments from drug and device companies to named physicians are public. Most results are small meals and travel and mean nothing. Occasionally they do not. Look before you assume either way.
5. Ask whether a treating clinician was ever consulted Ask directly whether the reviewer spoke to any of your treating providers, and offer a peer-to-peer conversation in writing. A decision made without speaking to anyone who has examined you, when clinicians offered, is worth naming in the record.

What this is for, and what it is not for

This is not about discrediting a person. Attacking a reviewer personally reads badly and does not move a file. What it is for is the plan’s process: a plan that assigns a claim to someone with no relevant expertise, or refuses to say who decided, has a procedural problem, and procedural problems are what appeals are good at.

Keep the tone flat. State what you asked for, what you were given, and what the record shows. Let the gap speak.

Look before you conclude

Most of what you find will be unremarkable, and that is a real answer too. A reviewer in the right specialty with a normal practice and trivial industry payments tells you this particular line of argument is not where your case is strongest, which is worth knowing before you spend a paragraph on it.

The rule that applies here is the same one that applies everywhere else on this site: check it, then say it. An accusation you cannot document costs you credibility on the parts of your appeal that are solid.

Common questions

Can I really ask who denied my claim? You can always ask. Plans are generally required to disclose the clinical rationale and, on request, information about the reviewer’s qualifications. Whether you get a name varies. Ask in writing and keep the answer or the non-answer.

What is a peer-to-peer review? A conversation between your treating clinician and the plan’s reviewer, and the one move that can undo a clinical denial without spending a level of appeal. It usually has to happen BEFORE you file. How to ask, and when.

Do industry payments mean the review was biased? No, and do not say that they do. The vast majority are meals and conference travel. The reason to look is to know rather than to guess, and occasionally the number is large enough to be worth a sentence.

Where this data comes from

The registry. Every clinician who bills insurance in the US has a National Provider Identifier. The registry is public and holds name, credentials, specialty and practice location.

The billing record. Medicare publishes which procedure codes each provider billed and how often. It covers Medicare fee-for-service only, so it is a partial picture and it is silent on commercial work — a clinician who does not take Medicare shows nothing here at all.

The payments. Under the Sunshine Act, drug and device companies report payments to physicians. Most entries are conference meals and travel. The reason to look is to know rather than to guess.