How to appeal a weight loss treatment denial in California

Start here: what was denied?

Once the plan gives its final answer you have 6 months to ask for an independent review, counted from any of the qualifying periods or events under Health and Safety Code section 1374.30, subdivision (j). That is the deadline you cannot get back.

Both figures come from California's own governing sections. Your notice states the limit for your case, and it is the document that decides it.

One check first: which kind of plan you have. No state rule reaches a self-funded employer plan, which is most job-based coverage, and a deadline taken from this page would be the wrong one.

The order the steps run in

1. Step one

   Read the notice, not a summary of it

   The notice you received is the document that governs your case. It names the reason for the denial, the deadline for challenging it, and where to send the challenge. Every later step depends on those three things, and no general page can replace them.

2. Step two

   Appeal to the plan

   The first challenge goes to the plan that issued the denial. It is a request for the plan to look again, and it is the step that has to be finished before anyone independent will look at the case.

3. Step three

   Ask for an independent review

   California runs its own external review program. A reader who has finished the plan's internal appeal asks that program for an independent review.

The clock

Every limit below was read from California's own governing sections, and the middle column is the one to check against your notice: two states with the same number and a different starting event do not have the same deadline.

You have to take the plan's grievance process first, but the plan cannot run the clock forever: section 1374.30 subdivision (j)(3) says you shall not be required to participate for more than 30 days, and section 1368 says the same thing from the department's side. After that you may go to the department whether or not the plan has answered.

An independent review costs you nothing in California. The statute is explicit that an enrollee pays no application or processing fees of any kind, and the Insurance Code says the same for a policy holder. Cost is a common reason people do not appeal, so it is worth knowing there is none.

Where the request goes, and who decides it

California Department of Managed Health Care, Help Center. The department contracts the review organizations and the statute requires them to be independent of any health care service plan doing business in California. You do not choose the reviewer and neither does your plan.

Both California Independent Medical Review Systems reach insurance the state regulates: a health care service plan under the Knox-Keene Act, or an insurance policy under the Insurance Code. Neither reaches a self funded employer plan, where the employer pays claims from its own funds and federal law governs the appeal instead. That is most people with job based coverage, so read which kind of plan you have before you take a deadline from this page. Medi-Cal is a third route again, with its own forum and its own clock, set out below.

What an external review is and what it can decide covers the step itself: who the reviewer has to be, what happens to the plan when they disagree with it, and how California's windows compare with the other published jurisdictions.

California publishes no standard form for this request, so the request goes in the way the forum above directs.

If the denial came from Medi-Cal

The Medi-Cal route is a different forum on a different clock, and the order matters. If the denial came from a Medi-Cal managed care plan, California section 10951 subdivision (b)(1) requires you to appeal to that plan FIRST, and then gives you 120 calendar days from the day the plan upholds its decision, or from the day your appeal is deemed exhausted, to ask for the state hearing. Filing in the wrong order is a common way to lose a right you had.

You can also read what the published record shows about weight loss drugs and Medi-Cal, which is useful background for an appeal even though it is not a rule.

What an appeal file usually contains

An appeal is a documents exercise. The plan denied a request against written criteria, so the reply that works is the one that shows the criteria being met, in the plan's own terms, with records from the people who treated you. The prescriber writes it; your job is usually to make sure nothing is missing.

• The denial notice itself, including any reference or case number on it.
• The criteria the plan applied, which the notice or the plan documents name.
• The prescriber's letter, written against those criteria rather than in general terms.
• The records that evidence each requirement the criteria list.

What a plan requires varies by plan, so treat this as the shape of a file rather than a checklist for yours. Where a plan's own criteria are published, the page for that plan type quotes them.

Which rule reaches your plan

The appeal route above is the one that applies when a state or federal rule reaches your plan. If your employer pays claims out of its own funds, the plan document sets the rules and the internal appeal is run under federal plan rules instead. Reading what the benchmark plans cover, California included is a fast way to see whether a state document reaches you at all.