The Peer-to-Peer Call That Can Reverse a Denial

What is a peer-to-peer review?

A peer-to-peer review is a direct conversation between the clinician treating the patient and a physician employed by the insurer, often called a medical director or medical reviewer. It is arranged after a denial, and its purpose is simple: to let the two clinicians discuss the case so the insurer's reviewer can reconsider. The reviewer can reverse the denial on the call, which is why it often resolves a dispute before any formal appeal begins 1Ref 1Project HEAL (2024).Single Case Agreements + Appeals.That a peer-to-peer review is a step in challenging a denial, and that the appeal ladder runs from peer-to-peer review through expedited or standard internal appeal to external review..

The review sits inside the insurer's utilization review process, the machinery a plan uses to decide whether a service is covered. Unlike a written appeal, a peer-to-peer is live and fast, and it turns a paperwork decision back into a clinical discussion between two people who both understand the medicine.

A peer-to-peer review is a live doctor-to-doctor call, arranged after a denial, in which the insurer's reviewer can reverse the decision on the spot.

When a peer-to-peer review happens

A peer-to-peer is usually triggered by a denial, and it can come at two moments. The first is when a plan denies a request to start a level of care. The second is during treatment, when a plan reviews an ongoing stay and denies further days; that mid-treatment decision is a concurrent review denial, and a peer-to-peer can be requested there too 1Ref 1Project HEAL (2024).Single Case Agreements + Appeals.That a peer-to-peer review is a step in challenging a denial, and that the appeal ladder runs from peer-to-peer review through expedited or standard internal appeal to external review..

Timing matters because the window is short. Many plans allow only a brief period to request the call after a denial, so the treating team generally moves quickly. The request itself is straightforward: the clinician, or the program's utilization review staff, contacts the insurer and asks to speak with the reviewing physician. Because eating-disorder care is stepped up and down as a person's stability changes, these reviews can recur across an episode of care, and each one is a fresh chance to make the clinical case 4Ref 4Frontiers in Psychology (peer-reviewed study) (2021).Predictors of Stepping Up to Higher Level of Care Among Eating Disorder Patients in a Partial Hospitalization Program.That level-of-care decisions to step up or down are driven by clinical progress and stability, and that transitions between levels are clinically consequential..

What the reviewing physician is deciding

The insurer's reviewer is almost never deciding whether the eating disorder is real. They are deciding whether the requested level of care meets the plan's definition of medical necessity, the standard a plan uses to judge whether a service at a given intensity is warranted by the person's condition. That is the whole of the conversation, and it is why the treating clinician's documentation carries the call.

Eating-disorder care is organized as a ladder, from outpatient through intensive outpatient, partial hospitalization, residential, and inpatient, and a person is meant to be at the level their medical and psychiatric stability requires 2Ref 2National Eating Disorders Association (2024).Levels of Care for Eating Disorders.The ladder of eating-disorder care from outpatient to inpatient, and that a person is placed at the level their medical and psychiatric stability requires.. Decisions to step up or down are driven by clinical progress and stability, and transitions between levels are clinically consequential 4Ref 4Frontiers in Psychology (peer-reviewed study) (2021).Predictors of Stepping Up to Higher Level of Care Among Eating Disorder Patients in a Partial Hospitalization Program.That level-of-care decisions to step up or down are driven by clinical progress and stability, and that transitions between levels are clinically consequential.. The peer-to-peer is where the treating clinician explains why the person sits where they sit on that ladder, against a reviewer who has never met them.

Medical necessity is the standard a plan uses to decide whether a service at a given level of care is warranted by the person's condition; it is what the peer-to-peer call is argued over.

How a clinician prepares for the call

The strongest peer-to-peer calls are the prepared ones. The treating clinician goes in with the clinical picture organized around the denial reason: the evaluation, the current risks, what a lower level of care would fail to manage, and why the recommended setting is the one the person needs. The argument answers the plan's specific words rather than restating that the person is unwell.

Parity belongs in the clinician's toolkit here. The federal parity law requires plans that cover behavioral health to apply treatment limitations no more restrictively than they do to medical and surgical care 3Ref 3Centers for Medicare & Medicaid Services (2024).The Mental Health Parity and Addiction Equity Act (MHPAEA).That MHPAEA generally requires plans to apply treatment limitations to behavioral-health benefits no more restrictively than to comparable medical and surgical benefits.. A clinician can press a reviewer on whether the criteria being applied to an eating-disorder stay match what the plan would apply to a comparable medical admission. Some denials arrive framed as the person being not sick enough for the level requested, and the clinician's job on the call is to show, from the record, why that framing is wrong.

• Answer the denial reason directly, in clinical terms.
• Name the risks a lower level would leave unmanaged.
• Invoke parity where the plan's behavioral criteria look stricter than its medical ones.
• Document the call: the reviewer's name, the date, and what was decided.

If the peer-to-peer does not work

A peer-to-peer can fail, and it is not the end of the road. If the reviewer upholds the denial, the next step is a formal internal appeal, in which the plan reconsiders on the written record. If that also fails, an external review lets an independent reviewer who does not work for the insurer look at the case and overturn the denial 1Ref 1Project HEAL (2024).Single Case Agreements + Appeals.That a peer-to-peer review is a step in challenging a denial, and that the appeal ladder runs from peer-to-peer review through expedited or standard internal appeal to external review.. Each stage has its own deadline, so calendaring them the moment a denial lands protects the later steps.

Families are not without backup. Federal consumer guidance is explicit that a person denied a mental-health benefit in error may have appeal rights and can seek help, including through their state insurance regulator 5Ref 5U.S. Department of Health and Human Services (2024).Mental Health and Substance Use Insurance Help.That a person denied a mental-health benefit in error may have appeal rights and can seek help, including through their state insurance regulator.. The peer-to-peer, the internal appeal, and the external review are rungs on one ladder, and losing the first rung simply moves the case to the next.

Why the level of care is worth fighting for

The stakes behind a peer-to-peer call are real, and they are why the effort is worth it. Eating disorders are among the most lethal psychiatric illnesses, so a decision that lands a person at too low a level of care is not a billing inconvenience 6Ref 6Arcelus J, Mitchell AJ, Wales J, Nielsen S (2011).Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies.That anorexia nervosa and related eating disorders carry markedly elevated mortality, placing eating disorders among the most lethal psychiatric illnesses.. Getting the level right is a clinical matter with clinical consequences, which is exactly what the treating team is trying to protect on the call.

The reviewer's job is to steward the plan's rules; the treating clinician's job is to steward the patient. When those two aims collide, the peer-to-peer is the structured place they meet. Families cannot make the call themselves, but they can make sure it happens: ask the treating team to request it promptly, and keep a written record of every step so the appeal that may follow starts on solid ground.