Insurance Denied a Telehealth Visit? Here's How to Appeal

Telehealth visits expanded dramatically during the COVID-19 pandemic, and federal and state regulators temporarily broadened coverage mandates to match. As emergency expansions have been rolled back, many patients are receiving unexpected denials for telehealth visits they assumed were covered. Understanding your rights under federal and state law is the key to a successful appeal.

Why Telehealth Claims Get Denied

• Service not covered under plan terms: The plan may not include telemedicine as a covered benefit, or may restrict it to certain specialties or clinical circumstances
• Provider not licensed in patient's state: Interstate telehealth requires provider licensure in the patient's state in most circumstances
• Post-pandemic rollback: Temporary emergency expansions authorized during the federal public health emergency (PHE) expired in May 2023, and many voluntary commercial insurer expansions were rolled back
• Modality mismatch: Audio-only visits may be treated differently than audio-video visits under some plan rules
• Coding errors: Telehealth visits must be billed with the appropriate Place of Service code (02 for telehealth, 10 for patient at home) and modifier (95 for synchronous telehealth)

Common denial codes: CO-50, CO-96 (non-covered charge), CO-4 (procedure code inconsistent with modifier).

How to Appeal a Telehealth Denial

Step 1: Identify the Specific Denial Reason

Determine whether the denial is a coverage exclusion, coding error, licensure issue, or modality restriction. Each requires a different response. First, verify the POS code (02 or 10) and modifier 95 were correctly applied — coding errors are a common and correctable cause of telehealth denials.

Step 2: Cite Your State's Telehealth Parity Law

Forty-three states and Washington D.C. have enacted some form of telehealth parity law requiring commercial insurers to cover telehealth services the same way they cover in-person services. Payment parity states (California, New York, Texas, and others) require insurers to reimburse telehealth at the same rate as in-person visits. Coverage parity states require that services covered in-person also be covered via telehealth. Identify your state's specific telehealth statute through the Center for Connected Health Policy (CCHP) state telehealth laws database at cchpca.org, and cite it directly in your appeal letter with the statute number.

Step 3: Invoke Federal Telehealth Protections

The CARES Act (2020) removed Medicare restrictions on originating site requirements during the public health emergency. The Consolidated Appropriations Act extended many Medicare telehealth flexibilities through 2024 and beyond. These extensions create pressure on commercial insurers to maintain similar access. If the same service is covered when delivered in-person but denied via telehealth, cite this disparity explicitly as a parity argument.

Step 4: Challenge Post-PHE Coverage Changes for Lack of Proper Disclosure

If a telehealth service was covered previously but is now denied following the PHE expiration, check whether your plan's current telehealth coverage policy properly notified you of the change. Under ERISA (29 U.S.C. § 1022), material benefit changes must be disclosed in advance through a Summary of Material Modifications (SMM). If the coverage reduction was not properly disclosed, this is a procedural ground for your appeal.

Mental Health Parity Act (MHPAEA) Explained" class="auto-link">mhpaea-parity-argument-for-mental-health-telehealth">Step 5: Make the MHPAEA Parity Argument for Mental Health Telehealth

For mental health telehealth specifically, MHPAEA (29 U.S.C. § 1185a) may apply if the denial results in more restrictive access to mental health telehealth than to equivalent medical/surgical telehealth services. Request documentation of how your insurer covers in-person mental health services and medical telehealth, and compare both to the denied mental health telehealth service.

Step 6: Request External Independent Review

If your internal appeal is denied, most states allow external independent review for telehealth disputes under ACA regulations (45 C.F.R. § 147.136). Request external review specifying that the reviewer should apply your state's telehealth parity law.

What to Include in Your Appeal

• State telehealth parity law citation with statute number and the specific coverage parity requirement
• Comparison of in-person coverage for the same service showing in-person is covered but telehealth is not (the parity disparity)
• Coding verification confirming correct POS code and Modifier 95 were applied
• Documentation of medical necessity for telehealth — distance, mobility limitations, infectious disease risk, access to specialty care
• ERISA Summary of Material Modifications request if coverage changed after the PHE without proper notice

Fight Back With ClaimBack

Telehealth denials are especially common post-pandemic — but state parity laws and strong clinical necessity arguments continue to win appeals. ClaimBack generates a professional appeal letter in 3 minutes. Start your free claim analysis → Free analysis · No credit card required · Takes 3 minutes

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal