How to Prepare for an External Review or Hearing

External Review Preparation

Organize Your Evidence

1. Chronological medical records — relevant dates of service and clinical notes
2. Denial correspondence — all denial letters, appeal letters, and responses
3. Clinical guidelines — specialty society guidelines supporting your position
4. Peer-reviewed literature — studies supporting the denied treatment
5. Physician letter of medical necessity — updated and specific to the denial reason

Build Your Argument

1. Address each denial reason individually and specifically
2. Show the reviewer missed something — new evidence, overlooked records, incorrect criteria
3. Explain why the treatment is necessary for YOUR case — generic arguments fail
4. Cite guidelines that support your position — specialty society, NCCN, ACR, etc.

ALJ Hearing Preparation

For Medicare and some state hearings, you may present in person:

1. Know the hearing format — phone, video, or in-person
2. Prepare opening statement — concise summary of your case
3. Organize exhibits — numbered and tabbed for easy reference
4. Prepare witnesses — treating physicians who can testify to medical necessity
5. Anticipate counter-arguments — know what the insurer will argue

Tips for Success

• The reviewer reading your external review case has limited time — make your strongest points clearly and early
• Include a clear summary page at the top of your submission
• Number all pages and create a table of contents
• Highlight key findings in medical records rather than submitting hundreds of unorganized pages