Tip: How to Appeal a Health Insurance Denial and Win

A coverage denial from your health insurer is not a final answer. It is the beginning of a process, and that process favors persistence. A significant percentage of appealed denials are overturned, which means most people who accept denials without appealing are leaving money on the table.

The first step after receiving a denial is to obtain the explanation in writing. The denial letter must state the specific reason for the denial and cite the plan provision or clinical criteria it is based on. This information drives your appeal strategy.

Internal appeal comes first. You submit a written appeal to your insurer with supporting documentation. Your physician should submit a letter of medical necessity that directly addresses the criteria cited in the denial. Peer-reviewed literature supporting the medical necessity of the treatment strengthens the appeal. Be specific and thorough. Vague appeals lose.

If the internal appeal is denied, you have the right to an external review by an independent organization. External reviews have a strong track record of overturning denials for services that are medically necessary. This step is free and binding on the insurer.

Meet every deadline in the process. Internal appeal windows are typically 180 days from the denial. External review requests have their own timelines. Missing a deadline can waive your rights.