Denial Reason
Prior Authorization Denied
Your insurer refused to pre-approve the procedure before treatment. This does not mean the treatment is wrong — it means the paperwork process was not completed to the insurer's satisfaction.
73%
Appeal success rate
KFF 2023
40%
External review overturn
NAIC data
What Strengthens Your Appeal
- ✓Letter of Medical Necessity from your treating physician citing your specific diagnosis and why the procedure is medically required
- ✓Published clinical guidelines (NCCN, AHA, ADA, AAOS) supporting the procedure for your diagnosis
- ✓Insurer's own clinical policy bulletin — show how your case meets their stated criteria
- ✓Documentation that no adequate alternative treatment has worked or is clinically appropriate
- ✓Peer-reviewed journal studies where available
Appeal Packet: What to Include
- 1Denial letter and Explanation of Benefits (EOB) with denial reason code
- 2Prior authorization request submitted by your provider, and any prior insurer responses
- 3Letter of Medical Necessity from your treating physician
- 4Clinical records showing your diagnosis, treatment history, and failed alternatives
- 5Published clinical guidelines supporting the procedure
- 6Copy of insurer's clinical policy bulletin for the procedure
What to Ask Your Doctor or Provider
Your provider plays a key role in your appeal. Ask them for:
- →A detailed Letter of Medical Necessity addressing the insurer's denial reason point by point
- →A summary of your diagnosis, failed alternatives, and why this procedure is the appropriate next step
- →Any peer-reviewed citations the provider can attach
- →A statement that delay of treatment would cause harm, if true
Step-by-Step Escalation
If your first appeal fails: Request an Independent External Review under ACA §2719. External reviewers are independent of your insurer and must decide within 60 days (72 hours for urgent care). External reviewers overturn insurer decisions in roughly 40–63% of cases.
1
File written internal appeal with supporting evidence
Deadline: Within 180 days of denial notice (60 days for Medicare Advantage)
2
Request Independent External Review (IRO)
Deadline: Within 4 months of internal denial
3
File complaint with your state insurance department
Find your regulator →4
Contact CMS or Department of Labor if plan is self-funded (ERISA)
Deadline: Within applicable statute of limitations
Procedure-Specific Prior Authorization Guides
Related Denial Reasons
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