Who reviews your internal appeal
The regulation requires a different, non-subordinate reviewer, and a separate medical consultant for medical-judgment denials.
Your appeal cannot be decided by the same person who denied the original claim, or by that person's subordinate. The regulation requires the review to be "conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual."
Where the denial is based in whole or in part on a medical judgment, such as whether a treatment was medically necessary, the reviewing fiduciary must also consult a health care professional with appropriate training and experience in the relevant field, and that professional must likewise be someone who was not consulted on the original denial (and not that person's subordinate either).
Why this matters for your appeal
If your complete claim file shows the same reviewer, or an obvious subordinate of the original decision-maker, handling your appeal, that is worth raising directly, in writing, as a procedural defect. See what the plan must disclose about medical and vocational experts for how to find out who was actually involved.
How to check who actually reviewed your appeal
Your denial letter and your complete claim file should identify the fiduciary who decided the appeal and, for a medical-judgment denial, the consulting health care professional. Compare those names against the individuals named in your original denial. If the file does not clearly identify who handled the appeal, or the same name or title appears at both stages, put that question to the plan in writing rather than assuming the requirement was met.
Sources
29 CFR 2560.503-1(h)(3)(ii), (h)(3)(v). Checked 2026-09-16.