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Federal law guarantees two appeal levels for most commercial plans: an internal appeal handled by the insurer, and an external appeal handled by an independent review organisation (IRO)

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Peer review Peer review information Nature Communications thanks Rudolf Oehler, Robert Hoffman and the other, anonymous, reviewer(s) for their contribution to the peer review of this work

Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, United States, 79905 Email: [email protected]