Adverse Determination

A payer's decision to deny, reduce, or terminate coverage for a requested healthcare service based on medical necessity, benefit coverage, or other criteria.

An adverse determination is the formal term for when a payer says no to a requested service. It covers denials of prior authorization requests, retrospective claim denials for medical necessity, and decisions to reduce or terminate ongoing treatment. Adverse determinations must follow specific regulatory requirements. The payer must notify you and the patient of the decision in writing, state the specific reason for the denial, identify the clinical criteria used, explain the appeal process including deadlines, and provide contact information for questions. For clinical adverse determinations (medical necessity denials), the decision must be made by a physician. A nurse or non-physician reviewer can approve a request, but only a physician can deny one. This is an NCQA requirement and is codified in many state laws. When you receive an adverse determination, you have the right to a peer-to-peer review. This means you can speak directly with the physician who made the denial decision and present your clinical case. Peer-to-peer reviews overturn a significant percentage of denials because the reviewing physician gets clinical context that was not in the written request. Timelines for responding to adverse determinations are strict. Standard appeals must typically be filed within 60 days. Expedited appeals for urgent situations must be decided within 72 hours. External reviews through independent review organizations are available after internal appeals are exhausted. Track your adverse determinations by payer and by service type. Patterns tell you something. If one payer denies 40% of your MRI requests while others deny 10%, either your documentation for that payer is inadequate or their criteria are more restrictive. Either way, understanding the pattern helps you address it. Do not accept adverse determinations without review. Many are overturned on appeal, especially when the denial was based on insufficient documentation rather than a genuine coverage exclusion.