How to appeal a health insurance denial: a step-by-step guide

To appeal a health insurance denial you file a written request asking the plan to reconsider, inside the deadline printed on your denial letter, and you attach the clinical evidence that answers the plan's own written criteria. That first step is called an internal appeal. If it fails, most people then have the right to an independent external review by a reviewer who does not work for the insurer.

The mechanics below are the general shape of the process. Your plan documents and your denial letter govern your case.

What is an appeal, exactly?

An appeal is a request to reconsider a coverage decision, not a complaint and not a lawsuit. The plan applied written criteria to whatever paperwork it had, and concluded the criteria were not met. An appeal puts a fuller record in front of a different reviewer and argues, against the same criteria, that they were.

Two things follow from that framing. The plan's criteria are the terrain, so getting them in writing comes before anything else. And an appeal is won or lost on the completeness of the record, not on the strength of the feeling behind it.

What are the levels of appeal?

For most plans there are two, sometimes three:

1. Internal appeal. The plan reviews its own decision. Commonly there is one level for individual and small group plans and two for some employer plans. Urgent cases can be expedited.
2. External review. An Independent Review Organization, with no financial relationship to the plan, reviews the case. Its decision binds the plan. The federal overview is on HealthCare.gov.
3. Regulator or program-specific routes. Medicare, Medicaid and state-regulated plans each add their own steps, hearings or complaint paths on top.

Which set applies depends on how your coverage is arranged, which is stated in your plan documents.

Step one: find the deadline

The date on the letter starts the clock. Internal appeal windows are commonly around 180 days from the denial for plans under the federal rules, though some plans and programs are shorter. Take the deadline from your own letter, not from a general figure, and calendar it the day you read it.

If a delay would put your health at serious risk, ask for an expedited appeal in the same breath as you file. Expedited review runs on a much shorter timetable, and the letter or your plan's member services line will say how to request it.

Step two: get the criteria and the file

Ask the plan in writing for the specific plan provision and the clinical criteria applied to your case, the reviewer's rationale, and the reviewer's credentials. Under the federal claims rules, plans generally have to provide the documents they relied on, free of charge.

This is the step most appeals skip, and it is the one that changes the argument from "please reconsider" to "here is where the record meets criterion 3(b)."

Step three: assemble the evidence

Gather, in date order:

• Office notes covering the diagnosis and the decision to treat.
• Objective findings: labs, imaging, functional measures, anything that shows severity or progression.
• Every treatment already tried, with dates, doses, duration and outcome, including intolerances and side effects.
• The order or prescription, and any prior authorization paperwork already filed.
• The denial letter and any earlier ones for the same care.
• Your clinician's supporting statement, where the plan requires one.

Step four: write the appeal

A useful appeal letter is short at the top and dense underneath. It states the claim and member numbers, the decision being appealed and its date, and the relief requested. Then it works through the plan's criteria in the plan's order, and for each one points to the specific record page or guideline that answers it. Where the plan named an alternative treatment, it explains clinically why that alternative is not appropriate for this patient.

Two habits matter more than eloquence. Cite what you assert, whether to the record or to a published guideline or drug label. And attach an index of what is enclosed, so a reviewer working through a stack can find the note you are referring to.

Submit it the way the letter says to submit it, keep a dated copy of everything, and confirm receipt.

Step five: what happens after you file?

The plan has a defined window to decide. Standard pre-service decisions are commonly around 30 days, post-service around 60, and expedited far shorter, but the governing numbers are in your plan documents. You should receive a written decision that states the reason and, if the answer is still no, explains how to request external review and by when.

An external review request usually has a tighter deadline than the internal appeal did. Do not let it pass while deciding what to do.

Does the kind of denial change the argument?

It changes it completely, even though the evidence overlaps. A "not medically necessary" decision is answered on medical necessity grounds, against the plan's clinical criteria. A prior authorization denial is often procedural before it is clinical. A step therapy denial turns on documented failures, contraindications and intolerances. A formulary exception turns on why the covered alternatives will not work for this patient.

If the letter arrived in the last day or two, start with what to do in the next 48 hours, which puts these steps in the order the clock demands.

Do you have to do this alone?

No. Your treating clinician's office can file a peer to peer review and supply a supporting statement. State consumer assistance programs and patient advocacy organizations help people file. And Cove Health exists for the part in the middle: a licensed physician reviews your records, tells you plainly whether the case has merit, and writes the guideline-cited letter to the party you designate.

No one can promise what a plan will decide. What can be controlled is whether the case in front of it is complete, specific and cited.