How to appeal a weight loss treatment denial in New York

A denial is a step in a process, not the end of one. In New York the route runs in a fixed order: an appeal to the plan first, then an independent review once the plan has given its final answer. This page sets out that order and who hears each stage.

By the Covered Weight editorial team · Updated Aug 6, 2026. Research and sourcing by Evan Reid.

Start here: what was denied?

A medication

72 hours

for the plan to decide a formulary exception, or 24 hours when the circumstances are exigent. This is a different and much shorter clock than the grievance rule below.

The drug clock, with its sources

A procedure, or care already given

30 days

for the plan to answer its own appeal. The independent review opens after that answer, on its own clock.

Every deadline, with what each one runs from

Once the plan gives its final answer you have 4 months to ask for an independent review, counted from the day the insured receives notice of the final adverse determination from the plan. That is the deadline you cannot get back.

Both figures come from New York's own governing sections. Your notice states the limit for your case, and it is the document that decides it.

One check first: which kind of plan you have. No state rule reaches a self-funded employer plan, which is most job-based coverage, and a deadline taken from this page would be the wrong one.

The order the steps run in

Step one
Read the notice, not a summary of it
The notice you received is the document that governs your case. It names the reason for the denial, the deadline for challenging it, and where to send the challenge. Every later step depends on those three things, and no general page can replace them.
Step two
Appeal to the plan
The first challenge goes to the plan that issued the denial. It is a request for the plan to look again, and it is the step that has to be finished before anyone independent will look at the case.
Step three
Ask for an independent review
New York runs its own external review program. A reader who has finished the plan's internal appeal asks that program for an independent review.

The clock

Every limit below was read from New York's own governing sections, and the middle column is the one to check against your notice: two states with the same number and a different starting event do not have the same deadline.

Appeal deadlines, with what each clock runs from and the section it was read from
Step	How long	The clock starts	Read from
Ask the plan to look againThe internal appeal. This is the step that has to finish first.	45 calendar days What this limit depends on Forty-five days is the FLOOR the law sets, not a ceiling: a plan must allow at least that long and may allow more. Your notice states what your plan allows, and that document governs your case.	receipt of notification of the initial utilization review determination	N.Y. Ins. Law § 4904(c) New York Insurance Law § 4904(c), at least forty-five days to appeal and thirty days to decide Insurance (ISC) CHAPTER 28, ARTICLE 49, TITLE 1, Section 4904, subdivision (c) New York State Senate · Source document · Read Aug 6, 2026 A utilization review agent must establish a period of no less than forty-five days after receipt of notification by the insured of the initial utilization review determination From subdivision (c). The same subdivision requires a determination on the appeal within thirty days of receipt of the information needed to conduct it. The url is a Wayback `id_` capture rather than the live page: www.nysenate.gov answers 403 to a self-identifying bot user-agent, so the weekly quote verifier could never re-read the live url and the corpus is FATAL on a quote no machine has read. Legitimate here because this is a statute, which carries its own revision date; it would not be legitimate for a fee or a phone number.
The plan's answer, treatment not yet receivedA pre-service denial: the care has not happened yet.	30 calendar days What this limit depends on Read the trigger carefully, because it is not the day you filed. The clock runs from the day the plan has the information it needs to decide, so sending a complete file at the start is the one thing that shortens it.	receipt of the information necessary to conduct the appeal	N.Y. Ins. Law § 4904(c) New York Insurance Law § 4904(c), thirty days to decide a standard internal appeal Insurance (ISC) CHAPTER 28, ARTICLE 49, TITLE 1, Section 4904, subdivision (c) New York State Senate · Source document · Read Aug 6, 2026 shall make a determination with regard to the appeal within thirty days of the receipt of necessary information to conduct the appeal The decision clause of subdivision (c), read from the section page text. Note the clock runs from receipt of the NECESSARY INFORMATION rather than from the filing. The url is a Wayback `id_` capture rather than the live page: www.nysenate.gov answers 403 to a self-identifying bot user-agent, so the weekly quote verifier could never re-read the live url and the corpus is FATAL on a quote no machine has read. Legitimate here because this is a statute, which carries its own revision date; it would not be legitimate for a fee or a phone number.
The plan's answer, treatment already receivedA post-service denial: a bill is already in play.	30 calendar days What this limit depends on One thirty-day rule covers both, so a denial you are already being billed for runs on the same clock as one for care you have not had.	receipt of the information necessary to conduct the appeal	N.Y. Ins. Law § 4904(c) New York Insurance Law § 4904(c), thirty days to decide a standard internal appeal Insurance (ISC) CHAPTER 28, ARTICLE 49, TITLE 1, Section 4904, subdivision (c) New York State Senate · Source document · Read Aug 6, 2026 shall make a determination with regard to the appeal within thirty days of the receipt of necessary information to conduct the appeal The decision clause of subdivision (c), read from the section page text. Note the clock runs from receipt of the NECESSARY INFORMATION rather than from the filing. The url is a Wayback `id_` capture rather than the live page: www.nysenate.gov answers 403 to a self-identifying bot user-agent, so the weekly quote verifier could never re-read the live url and the corpus is FATAL on a quote no machine has read. Legitimate here because this is a statute, which carries its own revision date; it would not be legitimate for a fee or a phone number.
The plan's answer when the case is urgentThe fast path. It exists only if the case meets the urgency test.	2 business days What this limit depends on Two BUSINESS days, which is the one place on this page where the distinction matters: filed on a Friday, that can land on Tuesday rather than Sunday.	receipt of the information necessary to conduct the appeal	N.Y. Ins. Law § 4904(b) New York Insurance Law § 4904(b), expedited appeals within two business days Insurance (ISC) CHAPTER 28, ARTICLE 49, TITLE 1, Section 4904, subdivision (b) New York State Senate · Source document · Read Aug 6, 2026 Expedited appeals shall be determined within two business days of receipt of necessary information to conduct such appeal From subdivision (b). The sentence continues with a twenty-four-hour rule for inpatient substance use disorder treatment, which is a different benefit from anything this site covers. The url is a Wayback `id_` capture rather than the live page: www.nysenate.gov answers 403 to a self-identifying bot user-agent, so the weekly quote verifier could never re-read the live url and the corpus is FATAL on a quote no machine has read. Legitimate here because this is a statute, which carries its own revision date; it would not be legitimate for a fee or a phone number.
Ask for an independent reviewThe outside review, after the plan has given its final answer.	4 months What this limit depends on Four months from the FINAL adverse determination, not from the first denial. The department's own program page states the same window.	the day the insured receives notice of the final adverse determination from the plan	N.Y. Ins. Law § 4914(b)(1) New York Insurance Law § 4914(b)(1), four months to initiate an external appeal Insurance (ISC) CHAPTER 28, ARTICLE 49, TITLE 2, Section 4914, subdivision (b)(1) New York State Senate · Source document · Read Aug 6, 2026 The insured shall have four months to initiate an external appeal after the insured receives notice from the health care plan From subdivision (b)(1). The sentence continues "or such plan's utilization review agent if applicable, of a final adverse determination or denial" and was trimmed for the 200-character limit. The url is a Wayback `id_` capture rather than the live page: www.nysenate.gov answers 403 to a self-identifying bot user-agent, so the weekly quote verifier could never re-read the live url and the corpus is FATAL on a quote no machine has read. Legitimate here because this is a statute, which carries its own revision date; it would not be legitimate for a fee or a phone number. New York State Department of Financial Services, New York State External Appeal, fee and filing New York State External Appeal, Fees New York State Department of Financial Services · Source document · Read Aug 6, 2026 Health plans may charge a $25.00 fee per appeal (but not more than $75.00 in a single plan year.) Read from the program page DFS itself runs, on 2026-08-06. Cited because the fee appears NOWHERE in Insurance Law 4914. The section was searched for "twenty-five" and for "fee", and its only fee provisions govern what the external appeal AGENT may charge and who pays the agent. The administering agency publishing its own program fee is the authority for it. The same page states the four-month filing window and gives (800) 400-8882 for help with an application.
The independent decision	30 calendar days What this limit depends on Thirty days from receipt of the request for the external appeal agent to decide.	receipt of the request	N.Y. Ins. Law § 4914(b)(2) New York Insurance Law § 4914(b)(2), determination within thirty days Insurance (ISC) CHAPTER 28, ARTICLE 49, TITLE 2, Section 4914, subdivision (b)(2) New York State Senate · Source document · Read Aug 6, 2026 The external appeal agent shall make a determination with regard to the appeal within thirty days of the receipt of the request From subdivision (b)(2), read from the section page text. The url is a Wayback `id_` capture rather than the live page: www.nysenate.gov answers 403 to a self-identifying bot user-agent, so the weekly quote verifier could never re-read the live url and the corpus is FATAL on a quote no machine has read. Legitimate here because this is a statute, which carries its own revision date; it would not be legitimate for a fee or a phone number.
The independent decision when the case is urgent	72 hours What this limit depends on Seventy-two hours is the outer limit for an expedited external appeal, and it is measured in hours rather than days.	the request	N.Y. Ins. Law § 4914(b)(3) New York Insurance Law § 4914(b)(3), expedited appeal completed within seventy-two hours Insurance (ISC) CHAPTER 28, ARTICLE 49, TITLE 2, Section 4914, subdivision (b)(3) New York State Senate · Source document · Read Aug 6, 2026 the external appeal shall be completed within no more than seventy-two hours of the request From subdivision (b)(3), read from the section page text. Seventy-two hours is the outer limit for an expedited external appeal. The url is a Wayback `id_` capture rather than the live page: www.nysenate.gov answers 403 to a self-identifying bot user-agent, so the weekly quote verifier could never re-read the live url and the corpus is FATAL on a quote no machine has read. Legitimate here because this is a statute, which carries its own revision date; it would not be legitimate for a fee or a phone number.

The external appeal opens once the plan has issued a final adverse determination on its own utilization review appeal, so the internal step comes first. New York does not state a deemed-exhaustion rule in the sections read for this record, so if your plan misses its own deadline, ask the department rather than assuming the external route has opened.

If a medication was denied rather than a procedure

No New York section read for this record points at the federal formulary exception rule, so this route reaches a New York reader through federal law directly rather than through a state hook. The state clocks above still govern the utilization review appeal. It does not reach every plan: the federal exception rule governs plans that must cover essential health benefits, so a self funded employer plan may run its own process instead. Read your plan documents before taking this clock.

A standard request: 72 hours; From the plan's receipt of the exception request. This limit comes from the federal exception rule rather than from a New York statute, so it reaches the plans required to cover essential health benefits and not necessarily yours. The state clocks above govern the utilization review appeal either way.; 45 C.F.R. § 156.122(c)(1)(ii)
When the circumstances are exigent: 24 hours; From the plan's receipt of the exception request. The exigent path is the federal one as well. If a prescriber can say in writing why waiting would harm you, that is the route to ask for.; 45 C.F.R. § 156.122(c)(2)(iii)

This is where New York differs from a state that charges nothing: a health plan may charge $25 for each external appeal, capped at $75 in a plan year. The plan is otherwise responsible for the cost of the appeal itself. If the fee is what is stopping you, ask the plan and the department about it rather than dropping the appeal.

Where the request goes, and who decides it

New York State Department of Financial Services, External Appeal Unit, 1-800-400-8882. The superintendent assigns the external appeal agent at random, by regulation. You do not choose the reviewer and neither does your plan, and the superintendent may set a maximum fee an agent charges or drop an agent whose fee is unreasonable.

The New York external appeal reaches insurance the state regulates: a policy issued in New York, or an HMO contract. It does not reach a self funded employer plan, where the employer pays claims from its own funds and federal law governs the appeal instead. That is most people with job based coverage, so read which kind of plan you have before you take a deadline from this page. Medicaid is a third route again, with its own forum and its own clock, set out below.

What an external review is and what it can decide covers the step itself: who the reviewer has to be, what happens to the plan when they disagree with it, and how New York's windows compare with the other published jurisdictions.

New York publishes no standard form for this request, so the request goes in the way the forum above directs.

If the denial came from New York Medicaid

The Medicaid route is a different forum on a different clock from the commercial one above, and the two are often confused. If a Medicaid managed care plan denied the care, that plan's own appeal comes first. Start from the notice the program sent you and follow the route it names.

Where a fair hearing goes, how long you have, and keeping benefits meanwhile

Where it goes: New York State Office of Temporary and Disability Assistance, Office of Administrative Hearings
How long you have: 60 days; From the date of the action or failure to act complained of. Sixty days is the New York rule for a fair hearing. If the denial came from a Medicaid managed care plan, federal rules require you to finish that plan's own appeal first and then give you between 90 and 120 calendar days from its notice of resolution, so check which of the two situations you are in before you count.

Keeping benefits while you argue

There is no number of days here, and that is the point: benefits keep running during the hearing only if the hearing is requested BEFORE the date of action on your notice. Find that date first, because it is the one deadline on this page that decides whether you keep coverage while you argue.

42 C.F.R. § 431.230(a)

You can also read what the published record shows about weight loss drugs and New York Medicaid, which is useful background for an appeal even though it is not a rule.

What an appeal file usually contains

An appeal is a documents exercise. The plan denied a request against written criteria, so the reply that works is the one that shows the criteria being met, in the plan's own terms, with records from the people who treated you. The prescriber writes it; your job is usually to make sure nothing is missing.

The denial notice itself, including any reference or case number on it.
The criteria the plan applied, which the notice or the plan documents name.
The prescriber's letter, written against those criteria rather than in general terms.
The records that evidence each requirement the criteria list.

What a plan requires varies by plan, so treat this as the shape of a file rather than a checklist for yours. Where a plan's own criteria are published, the page for that plan type quotes them.

Which rule reaches your plan

The appeal route above is the one that applies when a state or federal rule reaches your plan. If your employer pays claims out of its own funds, the plan document sets the rules and the internal appeal is run under federal plan rules instead. Reading what the benchmark plans cover, New York included is a fast way to see whether a state document reaches you at all.

Common questions

Can I go straight to an independent review?

Usually not. An external review normally starts only after the plan has given its final answer on an internal appeal, and filing out of order can cost you the review. The exception is an urgent case, where the two can run at the same time. Your notice says which applies.

How long do I have?

Read the notice you received. It sets the clock for your case and it is the authority, not this page. Covered Weight does not publish a deadline for a jurisdiction until it has read the governing document and can quote it, because a wrong deadline here is a right you cannot get back.

Who decides the external review?

New York runs its own external review program. A reader who has finished the plan's internal appeal asks that program for an independent review.

Is the appeal different under New York Medicaid?

Yes. A state program runs its own appeal and a fair hearing, on its own clock and in its own forum, and the order is not the same as it is for a commercial plan. Filing in the wrong forum is a common way to lose the right, so read the notice from the program rather than assuming the commercial route applies.