What Is a Peer-to-Peer Review?
A peer-to-peer review is a conversation between your healthcare provider and the insurance company's reviewing physician. The insurers' doctor and your doctor discuss your clinical case directly, with the goal of reaching consensus about medical necessity or appropriate treatment. Peer-to-peer reviews are often very effective — many insurers approve coverage after peer-to-peer discussion that they had denied initially.
Peer-to-peer reviews work because physicians often have different interpretations of clinical necessity. A conversation between clinicians can resolve disagreements faster than written appeals.
When to Request a Peer-to-Peer Review
Request peer-to-peer review when: your claim was denied as "not medically necessary," your provider believes the denial is clinically incorrect, the procedure is medically important and delay risks harm, or your written appeal was denied and you want escalation.
Your healthcare provider must request the peer-to-peer review from the insurance company. You cannot request it directly. Ask your provider's office to request it as part of your appeal.
Preparing for the Peer-to-Peer Review
Before the peer-to-peer, provide your healthcare provider with comprehensive documentation: your complete medical history relevant to the procedure, all diagnostic test results, images or prior imaging, documentation of conservative treatment attempts and outcomes, clinical guidelines supporting the procedure, and your specific functional limitations or symptoms.
Coach your provider on the key arguments: why standard alternatives won't work for your specific situation, what clinical evidence supports the procedure, and why delay would be harmful. The more prepared your provider is, the more persuasive the peer-to-peer conversation will be.
After the Peer-to-Peer Review
Ask your provider to request written confirmation of the peer-to-peer discussion outcome. If approval is granted, confirm it in writing before proceeding with the procedure. If still denied, request escalation or external review.