Your insurance denied a medication or treatment: what to do in the next 48 hours

If your plan just denied a medication or a treatment, do three things before anything else: find the appeal deadline printed on the denial letter, ask your plan in writing for the exact clinical criteria it applied, and start collecting the records your treating clinician has. A denial is a decision made from limited paperwork, and it is appealable. The steps below are the ones that keep every option open while you decide what to do.

What should you do in the first hour?

Read the letter end to end, twice, with a pen. Denial letters are written in two registers at once: an explanation for you, and a set of procedural facts for the appeal that follows. The second register is the one that matters right now.

Mark four things:

• The reason given. It is usually a short phrase: not medically necessary, prior authorization required, step therapy not met, non-formulary, out of network, or a coding or eligibility problem.
• The deadline to appeal. It is a date or a number of days, and it belongs to your plan, not to a rule of thumb you read online.
• The address, fax number or portal where an appeal is filed, and who it must be addressed to.
• The reference numbers: claim number, member ID, authorization or case number. Every later document needs them.

If the letter is vague about any of the four, that is normal, and it is a reason to call. Write down the date and time of the call, the name of the person you spoke to, and what they said. That log becomes part of the record.

Where is the appeal deadline, and how long do you have?

Internal appeal windows are commonly around 180 days from the date of the denial for plans covered by the federal rules, but the window that governs your case is the one printed on your own letter and in your plan documents. Some plans are shorter. Medicare Advantage, Medicaid managed care and self-funded employer plans each run on their own timetable.

Two other clocks matter. If waiting for a standard decision would seriously jeopardize your health or your ability to regain function, you can ask for an expedited appeal, which is decided far faster than a standard one. And if the denial is a prior authorization for care you have not yet received, treatment is on hold while the appeal runs, which is its own reason not to sit on the letter.

Put the deadline in a calendar today, with a reminder two weeks before it.

What should you ask the plan for, in writing?

Ask for the criteria and the file. Under the federal claims rules, a plan generally has to give you, free of charge, the documents it relied on: the specific coverage rule or clinical criteria applied to your case, and the reviewer's rationale. Request it in writing so there is a record, and keep it short:

I am requesting all documents, records and other information relevant to the denial dated [date], claim [number], including the specific plan provision and clinical criteria relied upon, and the credentials of the reviewer who made the determination.

This single request changes what an appeal can be. Before it, you are arguing against a phrase. After it, you are answering a written standard, point by point, with the record in front of you.

Which records should you gather?

Start with what your treating clinician already has, and ask for it now, because release requests take days:

• Office notes covering the condition and the decision to treat.
• Test results, imaging reports and lab values that show severity or progression.
• A list of every treatment already tried, with dates, doses, duration, and what happened. Failures, side effects and intolerances belong here; they are the heart of a step therapy or formulary argument.
• The prescription or order itself, and any prior authorization forms already submitted.
• The denial letter, and any earlier denial letters for the same care.

Keep them in one folder, digital or paper, in date order. An appeal that arrives complete is easier for a reviewer to act on than one that arrives in pieces.

Should your doctor be involved?

Yes, and early. Most plans allow the prescribing or treating clinician to file a peer to peer review, a direct call with the plan's medical reviewer, and for prior authorization denials that call is sometimes the fastest route to a different answer. Your clinician's office can also submit a supporting statement, which many plans require for a medication exception.

Their statement is necessary and it is usually brief. It rarely has room for the full history, the plan's own criteria, and the guideline citations that answer them. That gap is what a written appeal fills.

What if the denial is about a medication?

Then read the reason twice, because medication denials come in distinct kinds and each has a different path. If the plan wants you to try a cheaper drug first, that is step therapy. If the drug is not on the plan's list at all, you are looking at a formulary exception. If the plan is requiring approval before it will cover the prescription, that is prior authorization. And if the letter says the care itself was not warranted, that is a medical necessity decision.

The evidence you gather is largely the same. The argument is not.

What happens if the internal appeal is denied?

For most plans, an internal appeal is not the end. Federal law gives people in most plans the right to an internal appeal and then to an external review by an independent party outside the insurer, whose decision the plan must honor. The federal explanation of both steps is on HealthCare.gov, and the deadline to request external review is stated in the letter denying your internal appeal.

Very few people use any of this. In KFF's analysis of federal HealthCare.gov data, of 86 million denied in-network claims in 2023, consumers appealed 376,508 of them, an appeal rate under 1% (KFF, January 2025). The process exists whether or not it is used.

What if you cannot do this in 48 hours?

Most people cannot, and a missed hour is not a missed appeal. Do the two things with a clock on them: note the deadline, and send the written request for the criteria and the file. The records can follow.

If you would rather not assemble the argument yourself, that is what Cove Health does. A licensed physician reviews the records, says candidly whether the case has merit, and writes a guideline-cited letter to the party you designate. We cannot guarantee results, but you should not have to navigate this process alone.