Most US health plans deny medical cannabis claims. Cannabis is a Schedule I drug under federal law. Medicare, Medicaid, and most commercial plans exclude it. Three paths remain: a state coverage mandate, a workers' compensation claim, or a challenge to a procedural error in the denial. Each path has its own deadline.
Read the denial letter first
The letter states the reason code, the plan provision used, and the appeal deadline. Save the envelope and the date. A late filing ends the appeal. Ask the plan for the full claim file and the plan document (SPD) if you do not have them.
Identify the plan type
Insured plans sold in the state market follow state insurance law. Self-funded employer plans follow federal ERISA rules, and state cannabis mandates do not apply to them. Ask HR which type you have. That answer decides which appeal rights you hold.
File the internal appeal
ERISA group health plans must allow at least 180 days after a denial to file an internal appeal. Write a letter that cites the plan section, the diagnosis, the dose, and the prior treatments tried. Attach a letter from the prescriber that states medical necessity and the dosing schedule. Send it by trackable mail and keep a copy.
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Request external review
If the internal appeal fails, non-grandfathered ACA plans offer independent external review. You have four months from the final denial to request it. Standard decisions take up to 45 days. Expedited decisions take 72 hours. External review does not apply to excepted benefits such as standalone dental plans.
File a state insurance complaint
State departments of insurance accept complaints about insured plans. A complaint does not replace the appeal. It creates a record and can prompt the insurer to review the file.
Workers' compensation appeals
A few states require workers' comp carriers to reimburse medical cannabis. File that appeal with the state workers' comp board, not the health plan. Rules differ by state.
Documents to attach
- Copy of the denial letter and envelope
- Prescriber letter with diagnosis, dose, and duration
- Records of prior treatments and their outcomes
- The plan document section the denial cites
- Proof of payment for the medication, if you seek reimbursement
Common reasons appeals fail
Late filing, a prescriber letter without a dose, and appeals that do not address the plan exclusion. A citation to state law does not override a self-funded ERISA plan.