How to appeal a weight loss treatment denial in Ohio

A denial is a step in a process, not the end of one. In Ohio the route runs in a fixed order: an appeal to the plan first, then an independent review once the plan has given its final answer. This page sets out that order and who hears each stage.

By the Covered Weight editorial team · Updated Aug 6, 2026. Research and sourcing by Evan Reid.

Start here: what was denied?

A medication

72 hours

for the plan to decide a formulary exception, or 24 hours when the circumstances are exigent. This is a different and much shorter clock than the grievance rule below.

The drug clock, with its sources

A procedure, or care already given

30 days

for the plan to answer its own appeal. The independent review opens after that answer, on its own clock.

Every deadline, with what each one runs from

Once the plan gives its final answer you have 180 days to ask for an independent review, counted from the date of the final adverse benefit determination. That is the deadline you cannot get back.

Both figures come from Ohio'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

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.
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.
Step three
Ask for an independent review
Ohio 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 Ohio'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.

Appeal deadlines, with what each clock runs from and the section it was read from
Step	How long	The clock starts	Read from
Ask the plan to look againThe internal appeal. This is the step that has to finish first.	180 calendar days What this limit depends on Ohio does not set its own filing window for the internal appeal, so this is the federal floor for the plans the federal claims rules reach. Your notice states the limit your plan applies, and that document governs your case.	receipt of a notification of an adverse benefit determination	29 C.F.R. § 2560.503-1(h)(3)(i) 29 C.F.R. § 2560.503-1(h)(3)(i), at least 180 days to appeal an adverse benefit determination Code of Federal Regulations, Title 29, Part 2560 (Rules and Regulations for Administration and Enforcement), Section 2560.503-1 Claims procedure, paragraph (h)(3)(i) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · Read Aug 6, 2026 Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination Paragraph (h)(3)(i), read from the eCFR section page. This is the federal floor for the internal appeal, cited because California's own Act sets no filing deadline; it reaches the plans the federal claims rules apply to and not every plan.
The plan's answer, treatment not yet receivedA pre-service denial: the care has not happened yet.	30 calendar days What this limit depends on This is the federal rule for a plan offering one level of appeal, which is what Ohio allows for individual coverage.	the plan's receipt of the request for review	29 C.F.R. § 2560.503-1(i)(2)(ii) 29 C.F.R. § 2560.503-1(i)(2)(ii), 30 days to decide a pre-service appeal Code of Federal Regulations, Title 29, Part 2560 (Rules and Regulations for Administration and Enforcement), Section 2560.503-1 Claims procedure, paragraph (i)(2)(ii) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · Read Aug 6, 2026 such notification shall be provided not later than 30 days after receipt by the plan of the claimant's request for review of an adverse benefit determination Paragraph (i)(2)(ii), read from the eCFR section page. The clause opens "In the case of a group health plan that provides for one appeal of an adverse benefit determination". Ohio Revised Code § 3922.04, individual coverage may not require more than one level of internal appeal Ohio Revised Code / Title 39 Insurance / Chapter 3922, Section 3922.04 \| Exhaustion of issuer's internal appeal process Ohio General Assembly · Source document · Read Aug 6, 2026 shall not require more than one level of internal appeal before the individual may request an external review Read from the section page. The subject the clause governs is "individual health insurance coverage, including coverage offered to individuals through nonemployer groups", trimmed from the front to stay inside the 200-character limit. The printed section heading is "Exhaustion of issuer's internal appeal process".
The plan's answer, treatment already receivedA post-service denial: a bill is already in play.	60 calendar days What this limit depends on A post-service appeal gets 60 days rather than 30, so a denial you are already being billed for runs on a slower clock than one for care you have not had.	the plan's receipt of the request for review	29 C.F.R. § 2560.503-1(i)(2)(iii)(A) 29 C.F.R. § 2560.503-1(i)(2)(iii)(A), 60 days to decide a post-service appeal Code of Federal Regulations, Title 29, Part 2560 (Rules and Regulations for Administration and Enforcement), Section 2560.503-1 Claims procedure, paragraph (i)(2)(iii)(A) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · Read Aug 6, 2026 such notification shall be provided not later than 60 days after receipt by the plan of the claimant's request for review of an adverse benefit determination Paragraph (i)(2)(iii)(A), read from the eCFR section page. Same opening clause as the pre-service rule; the difference between the two is the 30 and the 60. 29 C.F.R. § 2560.503-1(i)(2)(ii), 30 days to decide a pre-service appeal Code of Federal Regulations, Title 29, Part 2560 (Rules and Regulations for Administration and Enforcement), Section 2560.503-1 Claims procedure, paragraph (i)(2)(ii) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · Read Aug 6, 2026 such notification shall be provided not later than 30 days after receipt by the plan of the claimant's request for review of an adverse benefit determination Paragraph (i)(2)(ii), read from the eCFR section page. The clause opens "In the case of a group health plan that provides for one appeal of an adverse benefit determination".
The plan's answer when the case is urgentThe fast path. It exists only if the case meets the urgency test.	Ohio's external review chapter does not set an expedited INTERNAL appeal clock, and this record does not invent one. Take it from your notice. What Ohio does give you is an expedited EXTERNAL review, and for that the request may be made orally rather than in writing.	the plan's receipt of the request	29 C.F.R. § 2560.503-1(h)(3)(i) Ohio Revised Code § 3922.02(B), an expedited review may be requested orally Ohio Revised Code / Title 39 Insurance / Chapter 3922, Section 3922.02 \| Request for review of adverse benefit determination, division (B) Ohio General Assembly · Source document · Read Aug 6, 2026 However, in the case of an expedited external review under section 3922.09 of the Revised Code, the review may be requested orally. The sentence following the 180-day rule in division (B). Worth rendering: the fast path does not require a written request, which matters when somebody is in hospital.
Ask for an independent reviewThe outside review, after the plan has given its final answer.	180 calendar days What this limit depends on One hundred and eighty days, which is generous next to most states, and the request goes to the health plan issuer rather than to the state. An expedited request may be made orally.	the date of the final adverse benefit determination	Ohio Rev. Code § 3922.02(B) Ohio Revised Code § 3922.02(B), 180 days to request an external review Ohio Revised Code / Title 39 Insurance / Chapter 3922, Section 3922.02 \| Request for review of adverse benefit determination, division (B) Ohio General Assembly · Source document · Read Aug 6, 2026 within one hundred eighty days of the date of the final adverse benefit determination From division (B), read from the section page at codes.ohio.gov on 2026-08-06. The sentence opens "All requests for external review shall be made in writing, including by electronic means, by the covered person to the health plan issuer" and was trimmed to stay inside the 200-character limit. Note the request goes to the ISSUER, not to the state. Ohio Revised Code § 3922.02(B), an expedited review may be requested orally Ohio Revised Code / Title 39 Insurance / Chapter 3922, Section 3922.02 \| Request for review of adverse benefit determination, division (B) Ohio General Assembly · Source document · Read Aug 6, 2026 However, in the case of an expedited external review under section 3922.09 of the Revised Code, the review may be requested orally. The sentence following the 180-day rule in division (B). Worth rendering: the fast path does not require a written request, which matters when somebody is in hospital.
The independent decision	30 calendar days What this limit depends on Thirty days from the issuer's receipt of the request, not from the day the reviewer got the file.	the health plan issuer's receipt of the request for a standard review	Ohio Rev. Code § 3922.05(H)(1) Ohio Revised Code § 3922.05(H)(1), decision within thirty days, or seventy-two hours if expedited Ohio Revised Code / Title 39 Insurance / Chapter 3922, Section 3922.05 \| Opportunities for external review by independent review organization, division (H)(1) Ohio General Assembly · Source document · Read Aug 6, 2026 shall provide written notice of its decision to either uphold or reverse the determination within thirty days of receipt by the health plan issuer of a request for a standard review From division (H)(1). The subject is "An independent review organization assigned to review an adverse benefit determination", and the clause continues with a seventy-two-hour rule for an expedited request; both were trimmed for the 200-character limit.
The independent decision when the case is urgent	72 hours What this limit depends on Seventy-two hours is the outer limit on a duty the statute otherwise words as “as expeditiously as the covered person’s medical condition requires”, which is a stronger rule than the number alone suggests.	the health plan issuer's receipt of the request for an expedited external review	Ohio Rev. Code § 3922.09(E) Ohio Revised Code § 3922.09(E), expedited external review within seventy-two hours Ohio Revised Code / Title 39 Insurance / Chapter 3922, Section 3922.09 \| Request for expedited external review, division (E) Ohio General Assembly · Source document · Read Aug 6, 2026 no more than seventy-two hours after receipt by the health plan issuer of a request for an expedited, external review, the assigned independent review organization shall uphold or reverse From division (E). The clause opens "As expeditiously as the covered person's medical condition requires, but", and the statute sets seventy-two hours as an outer limit on a duty that is otherwise as-fast-as-needed, which is a stronger rule than the number alone suggests. Ohio Revised Code § 3922.05(H)(1), decision within thirty days, or seventy-two hours if expedited Ohio Revised Code / Title 39 Insurance / Chapter 3922, Section 3922.05 \| Opportunities for external review by independent review organization, division (H)(1) Ohio General Assembly · Source document · Read Aug 6, 2026 shall provide written notice of its decision to either uphold or reverse the determination within thirty days of receipt by the health plan issuer of a request for a standard review From division (H)(1). The subject is "An independent review organization assigned to review an adverse benefit determination", and the clause continues with a seventy-two-hour rule for an expedited request; both were trimmed for the 200-character limit.

Ohio caps the internal appeal at ONE level for individual coverage, including coverage bought through a nonemployer group, so a plan cannot make you climb two ladders before the outside review opens. Note where the external request goes: to the health plan issuer, not to the state.

If a medication was denied rather than a procedure

No Ohio section read for this record points at the federal formulary exception rule, so it reaches an Ohio reader through federal law directly. Ohio's own contribution is on the other side of the process: it caps the internal appeal at one level for individual coverage and lets an expedited external review be requested orally. It does not reach every plan: the federal exception rule governs plans that must cover essential health benefits, so a self funded employer plan may run its own process instead. Read your plan documents before taking this clock.

A standard request: 72 hours; From the plan's receipt of the exception request. This limit comes from the federal exception rule rather than from the Ohio Revised Code. Ohio's own contribution sits on the other side of the process: it caps the internal appeal levels for individual coverage and lets an expedited external review be requested orally.; 45 C.F.R. § 156.122(c)(1)(ii)
When the circumstances are exigent: 24 hours; From the plan's receipt of the exception request. The exigent path is federal too. Ohio adds nothing to its timing, and nothing in the chapter read for this record shortens it.; 45 C.F.R. § 156.122(c)(2)(iii)

An independent review costs you nothing in Ohio. The health plan issuer pays for the external review, including one the superintendent orders. Cost is a common reason people do not appeal, so it is worth knowing Ohio puts none of it on you.

Where the request goes, and who decides it

Ohio Department of Insurance, Superintendent of Insurance. The superintendent assigns the independent review organization from a list the superintendent maintains. You do not choose the reviewer and neither does your plan.

Ohio's external review reaches insurance the state regulates. It does not reach 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. Medicaid 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 Ohio's windows compare with the other published jurisdictions.

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

If the denial came from Ohio Medicaid

The Medicaid route is a different forum on a different clock from the commercial one above, and the two are often confused. If a Medicaid managed care plan denied the care, that plan's own appeal comes first. Start from the notice the program sent you and follow the route it names.

Where a fair hearing goes, how long you have, and keeping benefits meanwhile

Where it goes: Ohio Department of Medicaid, with hearings conducted through the state hearing process
How long you have: See the note below; From the date of the action on your notice. Ohio's statute grants the hearing and does not print the number of days to ask for one, so this record does not state a figure. Take it from your notice. If a Medicaid managed care plan denied the care, that plan's own appeal comes first, and federal rules then give you between 90 and 120 calendar days from its notice of resolution.

Keeping benefits while you argue

There is no number of days here, and that is the point: benefits keep running during the hearing only if the hearing is requested BEFORE the date of action on your notice. Find that date first, because it is the one deadline on this page that decides whether you keep coverage while you argue.

42 C.F.R. § 431.230(a)

You can also read what the published record shows about weight loss drugs and Ohio Medicaid, 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, Ohio included is a fast way to see whether a state document reaches you at all.

Common questions

Can I go straight to an independent review?

Usually not. An external review normally starts only after the plan has given its final answer on an internal appeal, and filing out of order can cost you the review. The exception is an urgent case, where the two can run at the same time. Your notice says which applies.

How long do I have?

Read the notice you received. It sets the clock for your case and it is the authority, not this page. Covered Weight does not publish a deadline for a jurisdiction until it has read the governing document and can quote it, because a wrong deadline here is a right you cannot get back.

Who decides the external review?

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

Is the appeal different under Ohio Medicaid?

Yes. A state program runs its own appeal and a fair hearing, on its own clock and in its own forum, and the order is not the same as it is for a commercial plan. Filing in the wrong forum is a common way to lose the right, so read the notice from the program rather than assuming the commercial route applies.