What is meant by "explicitly excluded?"
Your health insurance evidence of coverage tells you what is covered under your plan. It will also have a section of exclusions. For example, some plans specifically exclude acupuncture; others might exclude coverage for dental procedures. Because these exclusions apply to all such services for all members, a request for a noncovered service is not eligible for external review.
Services that are covered under certain circumstances or when certain criteria are met are eligible for external review. For example, a health plan denies a procedure because it considers it to be cosmetic, but the patient's physician states that the procedure addresses a functional deformity. Such a denial would be considered an adverse determination and therefore eligible for external review.
What is a "final adverse determination?"
An adverse determination is a decision by the health plan to deny, reduce, modify or terminate an admission, continued inpatient stay, or the availability of any other health care services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care, or effectiveness. A final adverse determination is an adverse determination made after an insured has exhausted all remedies available through a health plan's formal internal grievance process.