Your Insurance Said No. Here's How to Write the Appeal.

I have my own health conditions. There are multiple medications that I have been on for years, but they aren’t included on my insurance company’s formulary (the list of approved medications that the insurance company will cover). So, how am I able to get the medications if they aren’t on the approved list? I am legally allowed to request a formulary exception (getting medication covered that is not on the list), meaning they have to let my doctor make her case for why I need it. She must make the argument for why the other medications on their list won’t work for me. Fortunately, my doctor has always made a good case, and I haven’t had to appeal any denials on my own. What about you?

Has your claim been denied? A claim is a request for your insurance company to pay for a medical visit or procedure after you’ve already had it. Has your prior authorization (when your doctor asks the insurance company to agree to pay for a procedure or medication before you get it) been denied?

If you’ve gotten a denial letter of any kind from the insurance company, appeal! I can’t say this enough. Many denials get overturned (you end up getting a yes, after you’ve gotten the initial no), so, appeal and get that chance. I highlighted this in my blog post, Your Insurance Said No. Now What? According to the American Medical Association (AMA), more than 80% of Medicare Advantage prior authorization appeals succeed, but only 0.2% of people file an appeal. Medicare Advantage is a type of Medicare plan, typically available to people 65 and older, though some people under 65 with certain disabilities also qualify. So, why don’t people appeal? One of the reasons people don’t file appeals is that it is overwhelming and requires a lot of time and effort most people don’t have.

Before you can write your appeal, you need to know your rights as a patient. In my blog post Your Insurance Said No. Now What?, I go over five patient rights that you have. In this post, I will go over five more rights, and then we’ll get into how to write that appeal. Let’s get into it.

Five Patient Rights

1) You have a right to a formulary exception.

This has everything to do with prescription medications. Here’s a quick explanation about medication formularies and tiers. First, a company that works for your insurance company, but is separate, decides which medications the insurance company will pay for. This is a formulary. Think of a formulary as the insurance company’s approved list of medications. Within that list, medications are sorted into tiers. Lower tiers cost you less. Higher tiers, like brand-name drugs, cost you more. There is a lot of controversy around these companies that determine formularies, but I’ll save that for a separate post. Let’s get back to your rights.

You have the right to request and gain access to medically appropriate medications not necessarily covered by your plan. The insurance company must pay for the medication for the full amount of time it is prescribed, override dosing limits (how much you can take), and lower your costs.

What does all of this boil down to? If your medication is “not covered,” ask for a formulary exception! It is fast, and if they deny it, you can appeal to a higher level. If the medication is necessary and no other medication will work, or if the alternatives could harm you, this lets you request full coverage and override limits on amounts of the medication prescribed. For formulary exceptions, a provider’s statement is sometimes required.

Legally speaking, “a health plan must have a process for an enrollee, the enrollee’s designee, or the enrollee’s prescribing physician (or other prescriber) to request a standard review of a decision that a drug is not covered by the plan.” 45 C.F.R. § 156.122 (c)

This means that your insurance company must have a process for you (the enrollee), someone you choose to speak on your behalf (your designee), or your prescribing provider to request a standard review of a decision that a drug is not covered by your plan.

You can ask for a 24-hour (1 business day) review for a formulary exception in exigent (extreme) circumstances: when you are suffering from a health condition that may seriously put your life, health, or ability to regain maximum function at risk or when you are already on a non-formulary drug and need a new prescription. The law backs this up.

“Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug.” (45 C.F.R. § 156.122 (c))

How long does the formulary exception last? It must last the duration of the prescription, including refills. One quick note here. In my experience, that usually ends up being a year because most plans don’t allow doctors to write prescription refills for longer than one year without having to submit a new prescription. However, a plan that grants the exception based on the extreme circumstances named above must provide coverage for the length of time that the extreme circumstances exist.

2) You have a right to have an adequate network of doctors.

“Health plans must maintain a network that is sufficient in number and types of providers to ensure that all services are accessible without unreasonable delay.” (45 CFR § 156.230)

Insurance companies must provide access to a sufficient number of providers within a reasonable distance or timeframe, making sure you can get care without long waits, excessive travel, or delays. What does this mean? Don’t settle for long waits or drives. Your plan must provide nearby care and a timeframe that meets your needs, not necessarily wants. If the network (the system of providers that are covered by your insurance company) falls short or if switching providers would cause a risky gap in your care, you might qualify for seeing a provider that isn’t in your network, but with your insurance company covering the additional cost associated with going outside your network.

3) You have a right to receive care in a setting that is safe, effective, and appropriate for your medical needs. This includes protection from being forced into unsafe, discriminatory, or inaccessible sites of care.

This means that insurance plans shouldn’t force you away from your medical team or into unsafe situations to get care, and the law backs this up. It’s worth the fight to stay in a safe environment with doctors who understand your needs.

“The patient has the right to receive care in a safe setting.” (ACA, 42 C.F.R. § 482.13(c))

4) You have a right to safe step therapy (when you have to try different medications that are similar to the one your doctor wishes to prescribe and fail on those medications, in order to get the medication your doctor wants to prescribe).

The insurance company usually wants you to do step therapy because similar medications are cheaper than the medication your doctor is trying to prescribe.

Unfortunately, this is not the law in all 50 states. In 38 states, laws protect you from being forced into potentially harmful or ineffective treatments through these “fail first” step therapy rules. These protections allow you to request exceptions to the step therapy rules when you are stable on your current treatment or the health plan’s preferred drug is unsafe. A preferred drug is a drug that is on the insurance company formulary as what they prefer, not necessarily what is best for you.

You have legal protections to request an exception if your insurance company’s preferred drug isn’t right or if you are stable on your current medication. Let’s dig a little deeper into what makes a preferred drug unsafe.

Under most states’ laws, and one proposed federal law, exceptions must be granted when any of the following apply to a health plan’s preferred drug therapy:

• Contraindication (when a medication can react with other medications, can trigger allergies you have, or is likely to cause adverse reactions (bad reactions to the medication))
• Expectation of ineffectiveness (won’t work) based on your medical history
• Previously tried and proven ineffective
• Expectation of worsening an existing co-morbid condition (another medical condition that you already have)
• Likelihood of a reduction in your ability to perform daily activities
• A barrier to adherence to your current therapy or care plan, meaning it makes it hard for you to stick to the plan your doctor has given you

There are now protections for those of you who have a Medicare Advantage plan, a Medicare plan that is run by a private company.

As of the 2024 plan year, the Centers for Medicare & Medicaid Services (CMS) prohibits Medicare Advantage plans from enforcing coverage criteria, including step therapy, that are stricter than traditional Medicare (Medicare Part A and Part B). (CMS)

5) You have the right for all of your copays (a set amount of money you pay before you receive a service or medication) to count toward your deductible (the amount you have to pay yourself before insurance pays a dime) and toward your out-of-pocket maximum (the maximum amount of money you pay before insurance pays your medical costs at 100%).

There are some medications that don’t have generic equivalents, meaning they don’t have a cheaper medication that has the same ingredients. The insurance company tries to tell you that your copay for that medication doesn’t count toward your deductible or out-of-pocket maximum because they are betting that you don’t know your rights and won’t push back.

How to Write an Appeal

Now that you know your rights, let’s talk about how to write that appeal. I need to be honest with you. When I first read through the best ways to write an appeal that has the best chance of being approved, I was intimidated. So, I am going to break these sections down so they are super simple. Don’t worry. We’ll get through this together.

I will tell you upfront that it’s not easy, and it takes time. Are you ready to buckle up for the ride? There are three parts you should include in your appeal to have the best chance at getting your claim covered or your medication or procedure pre-approved.

Here’s a breakdown of your appeal:

• Personal Impact, meaning how it affects you
• Clinical Evidence, the research of your medical conditions that proves you should get the procedure or medication
• Policy Compliance, what your insurance is supposed to cover, state or federal laws that support your case

Now, let’s break these down into bite-sized pieces and go one-by-one. We’ll get into the details of each of these parts.

Personal Impact

The first part is Personal Impact. This is where you get to talk about the physical, mental, emotional, life, and financial impact of your medical condition.

Some things to include:

My Diagnosis (Medical Condition) and How It Affects My Life

• Your condition/disease, including the diagnosis code (ICD-10 code), which you can get from your doctor
• Any other medical conditions that complicate your condition, meaning other conditions that occur at the same time as this medical condition, also called comorbidities
• Describe your specific symptoms, the effects of your medical condition, like pain, fatigue (when your whole body is tired but you aren’t sleepy), movement limitations, mental effects, as they relate to the denial, interruption of treatment, or when your symptoms first started.
• Describe the impact on your daily life, like working, caring for your family, performing basic tasks, sleep, and maintaining your mental health.
• Be specific. Describe what a typical day looks like for you. Your worst day, not your best day. They need to know the true impact of your medical condition.
• Name the activities you can no longer do or that cause you significant difficulty.
• Name the financial impact of not getting this medication, treatment, or procedure. One example is whether you can work your job the way you did before.

The point is to make the human cost of the denial so obvious that it cannot be denied.

This next part of the Personal Impact may or may not apply to you. Your insurance company may have made you try other medications first, also called step therapy, and you have to prove that those other medications have failed to help you before they will approve the actual medication your doctor prescribed. You want to show them that trying more medications with similar mechanisms of action (how they work for your specific condition) serves no medical purpose and only delays appropriate care.

Failure of Prior [Your Type of Medication] Meets Step Therapy Requirements

You can say something to the effect of, “I’ve made every reasonable effort to manage my condition with alternative treatments, the medications insurance has insisted upon, before arriving at [Medication Name You Need Approved]. I tried them, but they failed, either because they didn’t work or because of side effects I could not handle. Side effects are symptoms from the medication that are not what it’s supposed to do, like an allergic reaction, sleepiness, or nausea (feeling like you’re going to throw up).” This is what to include:

• Medication/Treatment
• Date(s) Used, it can be your best guess. It doesn’t have to be perfect.
• Outcome, why it failed, for example, no meaningful improvement after [X] number of months, or you had to stop it because of the side effects
• Lifestyle interventions, for example exercising or eating a specific diet

Clinical Evidence

The next part is Clinical Evidence. I’m not going to lie. This one is going to take research, which equals time, effort, and concentration, which can feel impossible when you are dealing with your medical condition. This part requires the most research, but is one of the most likely parts to determine if your appeal will succeed. So, it’s super important.

Thankfully, there is a new company, Inciteful Med, that helps with medical research and will make this part so much easier than it used to be. Inciteful Med uses artificial intelligence (AI, a computer system that can learn from large amounts of information and make decisions in ways that are similar to how a person thinks) to help you get the answers you need and is backed by science-based, peer-reviewed studies, meaning other experts in the field have reviewed and verified the research.

Always click on the link Inciteful Med provides to clinical studies to make sure the link is real and goes to the article it says it is referencing. AI can make mistakes. It’s better to be 100% sure of your source. Also, this site collects your information. The site is not yet HIPAA-compliant, which means your information isn’t kept safe like it is with your doctor. Personal health information (PHI) is information that can be directly linked to you. So, if you tell the AI everything about you, your name, your medical conditions, all of the medications you take, it could put all of that information together and store and use that information, according to their Terms and Conditions (where they list all of the detailed information of how their website and AI works and how information is handled). One way to potentially avoid creating PHI with this AI is to not create an account. That way your name is not connected to any of your searches. This is an incredible tool that can shave hours off your research time, and it’s your decision about how you feel about sharing your information.

You need to cite (call out and write down) recently published studies, medical guidelines, or expert recommendations that support your specific visit, test, medication, or procedure.

Using incitefulmed.com can save you hours researching the following for your condition:

• FDA approval and labeled indications (what the medication is approved to treat) for [Your Medication Name]. (The FDA is the federal department that tests and approves medications to make sure they are safe.)
• Published clinical trials (research studies where doctors test new treatments on people to see if they are safe and effective) demonstrating that the medication, treatment, or procedure works (look for landmark trials by name, well-known trials that make the strongest case for your situation)
• Comparative effectiveness studies (studies that compare how well a medication or procedure works) showing your medication or procedure is superior (significantly better) to the other options your insurance company wants you to try
• Review articles or meta-analyses in peer-reviewed journals (journal articles that have been reviewed by other doctors who are experts in whatever that journal article is about and who agree with what the author is saying)

Write out:

The clinical evidence supporting [Your Medication Name or Procedure] for the treatment of [Your Condition] is well-established:

[Study/Guideline 1—Name, Author, Year] demonstrated that [brief summary of what you found, for example, “patients treated with [Medication Name] achieved [X%] improvement in [outcome] compared to [other medication insurance is recommending].”]

I would recommend finding three studies or two studies and a guideline.

This is when incitefulmed.com would be especially helpful. You could type into the box, “Please find published, landmark clinical trials demonstrating the efficacy of [Your Medication Name/Your Medical Procedure] for [Your Medical Condition].” You are not asking it to find just any clinical trial. You are asking it to find published clinical trials that demonstrate how effective your medication or procedure is for your specific medical condition.

Or, you could type, “Please find meta-analyses in peer-reviewed journals for [Your Medication Name/Your Medical Procedure].” With this request, you are basically asking for an article in a medical journal in which researchers have researched the research. That’s a mouthful. It’s when researchers pull together research from dozens or thousands of studies and run statistics (the numbers of successes or failures of treatment) for all of them. It’s basically saying that researchers looked at every study on this, and the evidence across the board (every way you could look at it) supports this treatment. This is really powerful because it’s very hard for an insurance company to then say they disagree.

Now, if you can’t find meta-analyses, don’t panic! You don’t have to have them for your appeal to succeed. It is just one way to reinforce that your medication/procedure is without a doubt the best course of treatment for you. Any research at all will help your appeal, so don’t wear yourself out over it. You are trying to manage your life, even though you desperately need this medication or procedure to manage your medical condition.

I would like to pause for a moment and say: the fact that you, as a regular person, are being asked to do this research at all is wrong on so many levels. The insurance company is rigged against you. Instead of their experts approving medications and treatments that are desperately needed, they put the burden on you to prove that it’s needed.

Let’s get back into the appeal. Once you get some clinical evidence, you can say something like, “These findings confirm that [Medication Name/Procedure] is not an experimental or optional treatment. It is the evidence-based standard of care (the most common and expected type of care) for patients in my clinical situation.” What does all of this mean? You are just pointing out that the clinical trials, guidelines from medical organizations, or meta-analyses show that the visit, test, medication, or procedure you have gotten, or are asking to get, is standard treatment for your condition. It is not something that people are experimenting with or some optional treatment. No, it is standard, meaning most common and what is expected.

Getting the right citations (where you write out the exact clinical trial or guidelines) matters a lot. A strong appeal doesn’t just say “studies support this medication.” It names specific trials and directly addresses the insurance company’s stated reason for denial, which you can find on your Explanation of Benefits (the document sent by your insurance company detailing what was covered, what wasn’t, and how much you may owe). I’m going to say this first: don’t be scared by the next thing I write. You can do this. You need to be thoughtful and avoid errors. It can actually hurt your appeal if you cite retracted studies (studies that were published but then officially withdrawn because the data was flawed or the findings couldn’t be proven, so the journal or the researchers have to publicly withdraw them and say that their information is incorrect). Trials that aren’t relevant can also hurt your appeal. So, make sure that the studies and trials you put in your appeal directly relate to your situation. It’s better to have one study that is directly related to your test, medication, or procedure than three studies where only one applies. Does that make sense?

Policy Compliance

Your Denial Does Not Align With Your Own Coverage Policies

Review your insurance company’s Summary Plan Description (SPD), coverage policy bulletin, or formulary criteria (insurance-approved medical list requirements) for your medication, and verify which one your company uses. These are often publicly available on the insurance company’s website. Warning: these can be very dense, confusing, and frequently updated. These are the specific things to look for:

• The specific criteria (requirements) for coverage, for example, diagnosis codes or required prior medication failures
• Whether you already meet the criteria based on your treatment history
• Any contradictions between the denial reason and their own published policy
• Any examples of your insurance company approving coverage for a similar case or cases

You can write something similar to the following:

“According to [Your Insurance Company]’s own coverage policy for [Your Medication Name/drug class], coverage is approved when [summarize the relevant criteria, for example “the patient has a confirmed diagnosis of [Your Medical Condition] and has tried and failed at least two [Name the two alternative (other) treatments]”]. As documented above, I meet [all/each of] these criteria. The denial of my claim is therefore inconsistent with your own published guidelines.”

Applicable State and Federal Level

This is another part that requires research, which can be challenging. Unfortunately, I don’t have a shortcut for this research. To do this research, you have to know your insurance type: employer-based insurance (Do you get your insurance from your job?), the ACA marketplace (Do you buy your own insurance through the Affordable Care Act (ACA) marketplace, also known as Obamacare?), Medicaid (Do you get your insurance from the state because you have low income?), or Medicare (Do you get your insurance from the federal government because you are 65 years old or older or are on permanent, federal disability?)

It can help your appeal if you research laws specific to your state and insurance type (provided by your job, bought on the ACA marketplace, Medicaid, etc.). Knowing which laws apply to your specific plan type and state (and citing them accurately) can transform an appeal from a personal request to a legal demand. You can write it like this:

“[State]’s [Name the Relevant Law, Year] provides patients the right to [summarize the relevant protection, for example “an exception to step therapy requirements when the patient has previously tried and failed the required medications”]. My appeal meets the requirements for such an exception.

Additionally, [Your Insurance Company] was required to respond to my provider’s prior authorization request within [X] business days under [Citation to State Law or Regulation].”

Your insurance company is regulated (made to follow the rules) by either the state or the federal government. It’s essential to know which level of government regulates your insurance company, so that you can search either state laws or federal laws. The answer may surprise you.

Medicare is regulated by the federal government, so the state law research doesn’t apply to you. Medicaid is regulated jointly (both) by the federal and state government, and in specific situations, both federal minimums (the bare minimum standard set by federal law that states must meet) and state-specific laws may apply. States can provide more protections than the federal government but not less. I’ll cover both Medicaid and Medicare in more depth in an upcoming post.

State laws apply when you have a fully-insured plan. What does that mean? It means that you either buy your own insurance through the ACA (Obamacare) marketplace, or your employer (the company you work for) buys an insurance policy from an insurance company.

Federal law (ERISA) applies, not state law, when you have a self-funded employer plan. What does that mean? It means that your employer pays your claims directly, instead of your insurance company. Your employer only uses the insurance company to manage the plan, not pay out claims.

So, the natural question is: how in the heck do I find this out? If you are paying for your own health insurance through the ACA marketplace, you know that you are under state law. If you get your insurance through your job, speak with the Human Resources (HR) department, and ask them whether your plan is fully-insured or self-funded. Then, you will be able to move forward with your research, knowing whether to research state law or federal law.

Request for Review and Approval

Now, you wrap it all up by specifically and formally requesting review and approval. Include #3 below if your appeal qualifies for expedited (rushed) review, and add “expedited” into the section title above, for example, “Request Expedited Review and Approval.” Appeals qualify for expedited review when the standard timeframe could cause serious harm, such as if you are currently taking a medication and a denial would interrupt treatment, or if there’s medical evidence to support that delaying treatment would significantly worsen your health outcome.

“For the reasons set forth above, the documented failure of prior treatments, the clinical evidence supporting [Your Medication Name], the alignment with your own coverage criteria, and the serious health consequences of continued delay, I respectfully request that [Your Insurance Company]:

1. Approve coverage for [Your Medication Name/Procedure/Test/Visit] without further delay.
2. Override the [step therapy requirement/formulary exclusion/other barrier], consistent with the clinical evidence and my treatment history.
3. Process this appeal on an expedited basis, given the direct risk to my health from continued interruption of care (when care is stopped).

Please contact me at [Phone Number] or [Email Address] within the 72-hour timeframe (3 days) required by [Your State]’s law with your decision.”

Supporting Documentation Enclosed

Include any documentation that supports your appeal, including:

• Letter of Medical Necessity from [Your Provider’s Name, Credentials (the letters after their name, for example, MD or DO)]

Ask your provider for a “Letter of Medical Necessity” (where your provider explains why what you need is medically necessary). You may or may not be successful with this request, and that is okay. Not all providers have the time to write letters of medical necessity. That’s not on you, but it is worth the ask.

• Relevant medical records and treatment history, meaning medical records or treatment history that relate directly to your appeal

Also, if you have access to any of these, be sure to include them. You can get them from your provider, but trying to get them may take longer than you have to wait for your appeal. Getting medical records can take up to a month, and you, most likely, don’t have that kind of time to wait.

• Published clinical studies and guidelines referenced in this letter

Be sure to include copies of any published studies and guidelines that you have referenced in this appeal. It makes it so that the reviewer (the person who reviews your appeal) doesn’t have to spend their time searching for it for themselves.

• [Any additional documents: prior appeal decisions, lab results, imaging, etc.]

Then, type “sincerely” and your full name.

Citations & References

Next, include all of the citations and references (a specific way of writing out where you got your information) from your appeal. Having an appeal with correct citations signals to your reviewer that your case is grounded in evidence, as well as emotion. Emotion matters. Evidence makes it stronger. List every single study, guideline, and law you referenced in your appeal. To be a correct citation, it must fit these formats exactly. You can use the fill-in-the-blank formats for the most common citation types below.

Clinical Studies & Guidelines

[Last Name of First Author] et al. “[Title of Study].” [Journal Name], vol. [Volume], no. [Issue], [Year], pp. [Page Range]. DOI: [DOI Number or URL]. — Cited for: [Brief note on what this study supports in your appeal, for example, “Efficacy (how well it works) of [Medication] vs. placebo (when you are given a pill that doesn’t have the actual medication in it, but you think you got the medication) in [Condition]”]

Insurer Coverage Policies

[Insurance Company Name]. “[Title of Clinical Policy Bulletin or Coverage Policy].” Policy No. [Number], effective [Date]. Available at: [URL]. — Cited for: [for example, “Insurance Company’s own criteria for coverage of [Medication], which the patient meets”]

State & Federal Law

[State Name] [Name of Law or Act], [Bill Number if applicable], [Statutory Citation — e.g., 215 ILCS 134/XX], ([Year Enacted]). — Cited for: [for example, “Step therapy override rights when patient has failed required prior treatments”]

Prior Appeal Precedents

[Case or Decision Reference — for example, External Review Case No. XXXX], [Reviewing Body — for example, State Department of Insurance / Independent Review Organization], [Date of Decision]. — Cited for: [for example, “Denial overturned for patient with similar diagnosis and treatment history”]

Conclusion

This may all seem like a lot. And, it is. As I said before, this should never be your responsibility. You should not have to prove your case. They have access to all of the information, but they choose not to access it. It is sickening that patients or caregivers are being asked to do clinical research and legal research to get their medical needs met. Here’s the thing: you just need to do YOUR best. The two biggest takeaways from this post are: 1) Appeal, even if it is based only on your Explanation of Benefits and a personal letter written by you. Some appeal is better than no appeal. 2) Citations are great, but even one made-up citation can ruin your entire appeal.

Definitions

Preferred drug: a drug that the insurance company prefers over other drugs that are available

Comorbidities: medical conditions that occur at the same time

ICD-10 code: the code that is specific to your diagnosis (medical condition)

Non-formulary drug: a drug that is not on the insurance company’s list of approved drugs

Drug class: a group of medications that share similar properties, chemical structures, or treat the same condition

Coverage policy bulletin: a document that explains the insurance policy coverage

Standard of care: the most common and expected type of care

DOI (Digital Object Identifier, in the citation format): an identification number for digital information

Bill number (in the context of legislation): the number assigned to a specific law document

Statutory citation: the formal reference to a specific written law (statute), using its official code number

Formulary exclusion: when the insurance company specifically excludes a drug from coverage (the act of leaving it off the list)

External review: a review that is done outside, and separate from, the insurance company

Independent Review Organization: an organization that is separate from the insurance company that reviews insurance appeals

Prior appeal precedent: when the prior appeal has been approved before for someone else

Efficacy: a measure of how much something works

Medicare Part A: insurance from the federal government for people 65 years old or older (and some people who are eligible through permanent disability) that covers inpatient hospital stay (when you stay in the hospital), nursing homes, and hospice care (end-of-life care)

Medicare Part B: insurance from the federal government for people 65 years old or older (and some people who are eligible through permanent disability) that covers outpatient hospital visits, urgent care, and medical providers

Federal disability: when the federal government determines that you are permanently disabled (you have a medical disability that prevents you from being able to work)

SSDI (Social Security Disability Insurance): money you receive, monthly, from the federal government if you have a specific length of work history that would qualify you for Social Security when you are 65 years old, but the federal government has determined that you are permanently disabled

Department of Insurance: a state government agency that regulates insurance companies (making sure they are following the rules and requirements), enforces state insurance laws, provides licenses to insurance companies, and handles consumer complaints (your complaints as a person with health insurance) against the insurance company

ERISA (Employee Retirement Income Security Act): a federal law that sets standards for employer-sponsored (provided by your job) health and retirement plans and protects employees from unjust denial of benefits

Frequently Asked Questions

How long do I have to file an appeal after I receive a denial? You typically have 180 days (6 months), but check your denial letter and insurance plan documents for your specific deadline.

How long does the insurance company have to respond to my appeal? The timeframe may vary depending on your insurance company. Check with your insurance company. It also depends on the appeal.

For the ACA marketplace (Obamacare), these are the maximum timeframes the insurance company can take; however, if you appeal on multiple levels, the total time will take longer. Your insurance must provide you with a response in 72 hours for urgent care cases, 15 days for a prior authorization for a treatment, and 30 days for medical services you’ve already received. For a regular, external review, they must provide you with a response within 45 days. For an expedited external review, meaning a rushed one, they have 72 hours.

What happens if my appeal is denied? If your appeal gets denied, you can file another appeal to have someone separate from the insurance company review your appeal (external review). If that appeal gets denied, you can file an appeal to have a judge review your appeal (judicial review).

Can I appeal more than once? You can only appeal once to each level of review (internal appeal, external review, and judicial review).

What is the difference between an internal appeal and an external review? An internal appeal is done inside the insurance company, and it is done first. An external review is done outside, and separate from, the insurance company and is only done if the internal appeal is denied. You do have to ask for an external review if your internal appeal is denied. It does not happen automatically.

What is an Independent Review Organization, and how do I request a review from one? An Independent Review Organization (IRO) is an organization that is separate from your insurance company that reviews appeals after an internal appeal has been denied, also called an external review.

It is important to note that you can only request an external review after completing the internal appeal first. Here’s the process:

1. Check your denial letter, from your internal appeal denial. Federal law requires your insurance company to include instructions for requesting an external review in their final internal appeal denial. The letter will name the organization and tell you how to contact them.
2. File within 4 months of receiving the final internal denial.
3. Submit your request with your insurance member ID (which can be found on your insurance card), a written explanation of why you disagree, and any supporting medical records or clinical evidence.

Timelines for the IRO: standard review must be decided within 45 days; expedited (rushed) review within 72 hours. Importantly, the IRO’s decision is binding on the insurance company, meaning they have to follow it.

Do I need a lawyer to write my appeal? No. You can write your own appeal.

Should I still appeal if my provider is appealing? Yes! You can both appeal at the same time. It creates pressure from two directions. If one is denied, the other one keeps going.

Can I use AI to write my appeal? Having an AI written appeal is better than no appeal; however, AI can make mistakes that aren’t always obvious. AI will invent things that look real, like referencing a clinical study or law that doesn’t exist. In an appeal, accuracy matters, so if you are going to use AI, check its work.

Can a family member or caregiver file the appeal on my behalf? A family member or caregiver can only file the appeal if they have legal documents that say they can act on your behalf.

Is there a fee to file an appeal? There is no fee to file an appeal.

How do I get my Explanation of Benefits? You will receive your Explanation of Benefits either in the mail or through the insurance company portal (your online account with the insurance company).

How do I find the specific state laws that apply to my insurance plan? The first step is finding out whether your plan is state-regulated or federally-regulated, because state laws apply to some plan types and federal laws apply to others. Here’s how it breaks down:

• For fully-insured plans (the ones you buy your own insurance through the ACA (Obamacare) marketplace, or your employer buys a policy from an insurance company), state laws apply.
• For self-funded employer plans (your employer pays your claims directly, using an insurance company only to manage the plan), federal law (ERISA) applies, not state law. This is more common at large companies than most people realize.

To find out which type you have, ask your Human Resources (HR) department or call the member services number on your insurance card and ask, “Is my plan fully-insured or self-funded?”

Once you know your plan type, go to your state’s Department of Insurance website and search “[Your State] Department of Insurance,” and look for their consumer health insurance section. That’s where the state-specific laws and consumer rights are listed. Useful starting points are HealthCare.gov and FindLaw’s state insurance guide.

What if I can’t find any clinical studies for my specific condition? If you can’t find any clinical studies for your specific condition, then you must send your appeal in without clinical evidence.

How do I know if a study has been retracted? The study must clearly state that it has been retracted.

What if I don’t know my ICD-10 code? You can call your provider’s office and ask them what your ICD-10 code is.

What if I’ve already paid the bill? Can I still appeal? Yes. As long as you have not gone past the deadline for an appeal, you can still appeal.

Do I have to include every document on the list, or just what I have? The goal is to try to include every document on the list, but if you don’t have everything, include what you do have.

What happens if the insurance company doesn’t respond within the required timeframe? You can file a complaint with your state’s Department of Insurance.

What is the Department of Insurance? The Department of Insurance is a department within your state that is in charge of enforcing the rules for all types of insurance, life, home, health, etc.

Can I file an appeal for a claim denial and a prior authorization denial at the same time? No, they are two different types of appeals. They need to be written as separate documents.

What if my condition isn’t covered in 38 states for step therapy? What are my options? Unfortunately, there are no other options right now.

What if I can’t get my medical records in time to submit my appeal? If you can’t get your medical records in time to submit your appeal, then you send the appeal in without your medical records.

Will citing clinical studies and laws really make a difference? Yes, as long as they’re accurate. Specific clinical evidence and laws that apply are what move an appeal from a personal request to a documented, legally grounded demand. Just be certain every citation is real and correctly stated, because a single fake reference can sink an otherwise strong appeal.

Sources

Tanya Albert Henry, “Over 80% of Prior Auth Appeals Succeed. Why aren’t there more?” AMA (American Medical Association), October 3, 2024.

Justin Lo, Michelle Long, Rayna Wallace, Meghan Salaga, and Kaye Pastaina, “Claims Denials and Appeals in the ACA Marketplace Plans in 2023,” KFF, January 27, 2025.

Alicia Graham, “Beginner’s Guide to Patient Appeals: 10 Essential Rights to Fight Health Insurance Denials,” Claimable, December 11, 2024.

Claimable. getclaimable.com. Accessed August 2026.

Healthcare Uncomplicated provides general health system education only and does not offer medical or legal advice. Always consult a qualified professional for your specific situation.

Coming Next Week: Medicaid, Medicare, ACA marketplace, what’s the difference?