When a plaintiff sues an insurer for bad faith denial, the central medical question is whether the insurer's physician reviewer applied criteria correctly. This article is written for insurance defense counsel and carrier legal teams from first-hand criteria application experience.
What makes a denial defensible
A defensible denial has four documentation characteristics. First, the stated criteria must actually apply to the clinical presentation — InterQual criteria for a medical admission must be the correct level-of-care criteria for the documented condition. Second, the denial rationale must address the specific clinical evidence rather than using boilerplate language that could apply to any case. Third, the peer-to-peer review with the treating physician must be documented — not just that it was attempted, but what was discussed and how the clinical information affected the determination. Fourth, the reviewer must be qualified in the relevant specialty.
What plaintiff attorneys look for
Plaintiff bad faith attorneys look for the gap between what the UR file contains and what the denial letter states. When the denial letter says "the medical record does not support medical necessity" but the UR file shows the reviewer spent minimal time with the record and did not address key clinical findings, that gap is the bad faith argument. A physician who has written thousands of these reviews can identify whether a specific denial will survive that scrutiny — because that physician knows what adequate review documentation looks like from the inside.
The UR process audit
The Medisprudence UR Process Audit evaluates the complete denial documentation: criteria application, rationale specificity, peer-to-peer documentation, reviewer qualification, and overall defensibility. The deliverable identifies specific remediation steps if deficiencies are found — actionable before plaintiff discovery, not after.