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Prior authorization denial

Prior authorization denied or stuck? Put a physician on it.

A licensed physician reads what your plan is actually asking for, then writes the letter that supplies it: the criteria, the records, and the urgency, in writing.

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No account needed to check. A physician tells you candidly if the case has no merit.

What this denial means

A prior-auth denial is usually a paperwork verdict, not a clinical one.

Prior authorization asks your plan to approve care before you receive it. The request is often filed by an office with minutes to spare, on a form with no room for context, so denials frequently turn on a missing chart note, an unclear code, or a criterion nobody spelled out.

The remedy is rarely to argue louder. It is to answer the specific criterion the plan applied with the specific record that satisfies it, and, when the delay itself is doing harm, to say so in the terms that trigger an expedited decision.

What the letter argues

Written by a licensed physician, cited line by line.

The exact criterion at issue

Denial letters cite a policy. The letter answers that policy on its own terms instead of restating the original request.

What the form could not hold

Chart notes, imaging, prior treatments and dates: the evidence the request assumed but never showed.

Clinical urgency, on the record

Where waiting risks harm, the letter says so explicitly and asks for expedited review, which carries far shorter deadlines.

A named recipient and a clock

The letter goes to the party you designate (your plan, the reviewing physician, a government body) and states the response window it is owed.

Medication guides

Denied a specific medication?

ADHD stimulants denied: Adderall, Vyvanse and ConcertaStimulant denials mix prior authorization criteria, age rules and quantity limits, and sometimes a shortage is mistaken for a denial. Here is how to tell them apart and what an appeal has to show.Adderall XRVyvanseConcertaRead the guide →GLP-1 medications denied: Ozempic, Wegovy, Mounjaro and ZepboundGLP-1 denials usually turn on prior authorization criteria or on whether your plan covers weight-management drugs at all. Here is how to tell which one you are facing, and what an appeal has to show.OzempicWegovyMounjaroRead the guide →Hepatitis C antivirals denied: Mavyret, Epclusa and HarvoniHepatitis C treatment is usually gated behind prior authorization, and denials often rest on restrictions that many payers have since removed. Here is what the criteria ask for and how an appeal answers them.MavyretEpclusaHarvoniRead the guide →

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After the internal appeal

If your plan denies the appeal, your state has a next step.

External review sends the decision to clinicians who do not work for your plan. Who runs it, and how long you have to ask, depends on where you live: we keep a page for each of the 51 states and the District of Columbia, linked to the regulator's own filing page.

Find external review in my state →

Resources

Not ready to start a case? That’s okay. Start here.

Start hereYour insurance denied a medication or treatment: what to do in the next 48 hoursA denial letter starts a clock. Here is what to read, what to request, and what to gather in the two days after it arrives, in the order it usually matters.Read the Guide →

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Getting started

From a stalled authorization to a physician-signed request, in four steps.

1

Tell us what happened

Share your denial and some basic information about the medication or treatment your doctor recommended. Don’t worry if you don’t know exactly what kind of denial you have.

2

We review your case

A licensed Cove Health physician reviews your information, the reason for the denial, and the medical and coverage criteria that may apply to your case.

3

We build the case for your care

Your Cove Health physician uses medical evidence, clinical guidelines, and Cove Health’s technology to develop a clear, well-supported case for the care your doctor recommended.

4

We help you take the next step

We help you understand what comes next and advocate on your behalf based on the needs of your case.

Appeal deadlines are set by your health plan and/or applicable law, and you remain responsible for meeting them. Submitting a case does not guarantee that an appeal can be completed or filed before your deadline unless Cove expressly confirms otherwise.

Simple, honest pricing

One issue or many, we've got you.

Single Case
One issue, fully handled: review, drafting, and advocacy.
$100 flat fee
  • ✓ Licensed physician review of your records
  • ✓ One fully drafted, guideline-cited advocacy letter
  • ✓ Sent to the party of your choice
  • ✓ No subscription, no commitment
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For patients juggling multiple issues across plans and providers.
$29.99 / month
Two-month minimum, then month to month
  • ✓ Ongoing advocacy across multiple issues
  • ✓ Priority physician review
  • ✓ Unlimited letters while subscribed
  • ✓Continuous case tracking & follow-ups
Become a member

The membership starts with a two-month minimum commitment. If you cancel during those first two months, the remaining balance for the commitment is still due and will be charged. After the initial two months it continues month to month until you cancel.

Appeal deadlines are set by your health plan and/or applicable law, and you remain responsible for meeting them. Submitting a case does not guarantee that an appeal can be completed or filed before your deadline unless Cove expressly confirms otherwise.

Cove Health provides non-legal patient advocacy. We are not a law firm and do not provide legal representation.

Frequently asked questions

Prior authorization denials, answered.

How is a prior-authorization denial different from a claim denial? +
Prior authorization happens before care; a claim denial happens after it. The practical difference is timing. With prior auth the treatment has not started yet, so an expedited appeal can matter enormously.
My doctor's office already appealed. Can you still help? +
Yes. A second, independent letter that engages the plan's stated criteria directly is often what moves a case, and it draws on records and authorities a busy office rarely has time to assemble.
What about a peer-to-peer review? +
That is a call between your treating physician and the plan's reviewer. It can help, but it is brief and leaves little trace. A written, cited letter puts the same argument on the record, where it has to be answered.
How quickly can this move? +
Expedited review exists for situations where the standard window would jeopardize your health, and it runs on much shorter deadlines. Your denial letter and plan documents state which windows apply to you.
Do you contact my insurance directly? +
Only where you authorize it. You designate the recipient of every advocacy letter: your plan, another physician, a government body, or a workplace program.

Still have a question?

Common insurance problems

Facing a different denial?

“Your care isn’t medically necessary.”Medical necessityYour insurer says the medication or treatment your doctor recommended does not meet its criteria for medical necessity.How Cove Health can help →“You need to try something else first.”Step therapyYour insurer requires you to try another medication or treatment before it will cover the one your doctor recommended.How Cove Health can help →“Your medication isn’t covered.”Formulary exceptionYour medication may not be on your insurance plan’s covered drug list, or your insurer may require an exception before it will cover it.How Cove Health can help →
Next step

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