Second-Level Appeal, First-Class Defense

A self-funded health plan received a second-level appeal from a participant after initial and first-level denials for an expensive out-of-network procedure. The claim had been denied based on plan exclusions for experimental and investigational treatments and lack of medical necessity. The second-level appeal included new documentation, including a physician’s letter and supporting medical literature. Concerned about fiduciary risk and potential legal exposure, the plan sponsor knew they needed an objective third-party review.

As the PACE, The Phia Group reviewed the full case, including medical records, appeal letters, and the applicable Plan Document, and obtained a medical opinion from a board-certified surgeon. The Phia Group confirmed that the denial aligned with the Plan’s clearly defined exclusion for experimental and investigational procedures. The new documentation did not change the fact that the treatment fell outside covered services.

By partnering with The Phia Group, the Plan avoided over $45,000 in ineligible payments and remained consistent in applying its benefits. This case reinforced the value of expert support during complex appeal stages to reduce liability and protect plan assets.