A peer-to-peer review is when your treating physician speaks directly with the insurance company's medical director about your case. This can be one of the most effective ways to overturn a medical necessity denial — if your doctor is well-prepared.
What Is a Peer-to-Peer Review?
During a peer-to-peer (P2P) review:
- Your doctor calls the insurer's medical director
- They discuss the clinical rationale for the denied treatment
- The insurer's doctor can overturn the denial on the spot
- Usually lasts 10-30 minutes
When to Request P2P
- Medical necessity denials
- Prior authorization denials
- When your doctor has a strong clinical case
- When the denial seems to misunderstand the clinical situation
Preparation Checklist for Your Doctor
- Review the denial reason and insurer's clinical criteria
- Have all relevant records ready (lab results, imaging, history)
- Prepare a concise clinical argument addressing each denial criterion
- Know what alternative treatments have been tried (and why they failed)
- Have peer-reviewed evidence ready to cite
- Be professional — this is a clinical discussion, not a debate
Common P2P Strategies
- Frame the discussion around the patient's specific clinical circumstances
- Address each coverage criterion the insurer cited
- Emphasize failed conservative treatments (step therapy exhaustion)
- Cite current clinical guidelines from relevant specialty societies
- Document the conversation — note the reviewer's name, date, and outcome
If P2P Doesn't Work
- Proceed to formal internal appeal with the documentation
- Note what the insurer's reviewer said — address those points in your written appeal
- Request external review if internal appeal fails