Who typically performs peer reviews to overturn a denial during the appeals process?

• A. A patient-selected advocate
• B. A peer review by qualified clinicians not involved in the initial decision
• C. The plan's marketing team
• D. The hospital's infection control committee

Answer: (B)

Peer reviews in the appeals process are conducted by independent, qualified clinicians who were not involved in the original denial. This separation ensures an objective, expert evaluation of whether the requested care meets medical necessity and aligns with current guidelines. The reviewer examines the patient’s records, the requested treatment, and the insurer’s criteria, applying evidence-based standards relevant to the condition. If the reviewer finds the denial lacks support, they can overturn the decision and authorize the service.

Other options don’t fit because a patient-selected advocate assists with navigation and advocacy but does not perform the clinical review; the plan’s marketing team has no role in determining medical necessity; and the hospital’s infection control committee focuses on infection prevention, not coverage decisions.