Your Insurance Said No. You Can Fight Back.

My husband, Jarrod, had colorectal cancer. He had radiation, surgery, chemotherapy, a clinical trial, and more radiation. His PET scan showed that he was stage 4, meaning he still had tumors in his lungs, but the tumors were stable. The cancer had not spread further.

Then he started having symptoms. The pain became so excruciating that we took him to the Emergency Department. The ED doctor ordered a CT scan, which looks for solid tumors throughout the body. Everything came back normal. They gave Jarrod morphine for the pain. We waited about a week to see if it would help. It didn’t. I called my uncle, who is a retired orthopedic surgeon, to see if there was anything he could do. He called someone at his former practice, and that colleague fit us in that same day. He even stayed late to make sure it got done. Jarrod got an MRI to check whether the cancer had spread to his bones. It came back normal too. When we called Jarrod’s oncologist, he prescribed stronger morphine and told us that Jarrod couldn’t have a PET scan, which detects cancer activity throughout the body, until July.

We were close to his oncologist. He cared deeply about Jarrod. He wasn’t trying to withhold anything. He was hoping the higher dose of morphine would help manage the pain. It didn’t work. Jarrod spent months laid out on the couch or in bed, just waiting.

In July, the oncologist booked the PET scan the moment Jarrod was eligible. The results came back in August. His cancer had spread to his adrenal gland, his liver, and seven bones.

We were devastated. But we didn’t know we could have pushed back. His oncologist told us Jarrod wasn’t eligible yet, and we accepted it. I know now that we could have questioned it. We might have gotten the scan sooner. Jarrod might have started treatment sooner. I want you to know what we didn’t.

The rule his oncologist was following was set by the insurance company. What Jarrod and I didn’t know was that we, as patients, could have pushed back on it ourselves. That is what I want to walk you through today.

There are two types of denials. One denial is for a prior authorization (prior auth), which is asking the insurance company to approve your medication or procedure before you receive it. The other type of denial is a claim denial after the fact. Let’s go through each of them and what you can do.

Prior Auth Denials

Let’s say your doctor wants you to get a PET scan to check and see if your cancer has metastasized, meaning the cancer has spread to other parts of your body. The doctor submits a prior authorization to make sure the insurance company agrees to pay for the scan. The insurance company may say, “No.” This is a prior authorization denial.

After-the-Fact Denials

Let’s say you have a procedure. After you get the procedure, you find out that your insurance company is not going to pay for it. There are multiple reasons your insurance company can deny your claim: failing to get a prior auth, an out-of-network provider, meaning the provider doesn’t have a contract with the insurance company, incorrect billing codes, which are the numbers the billing department uses to inform the insurance company of which test, visit, or procedure occurred, missed claim deadlines, wrong patient information, among others.

So, My Insurance Denied My Claim. Now What?

Appeal the decision, whether it’s for a prior auth denial or an after-the-fact claim denial. According to the American Medical Association (AMA), more than 80% of Medicare Advantage prior auth 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.

I recently learned about Claimable. Claimable is an artificial intelligence (AI) platform that builds a custom, science-based appeal on your behalf. They only do medication denials. They do not do procedure denials or paperwork errors, like filing errors, wrong codes, and missing information. 80% of Claimable appeals are successful, with most resolved in 10 days or less. This is very fast, which you will understand better later in the post. All you have to do is submit your denial notice and insurance information, and answer simple questions about your health. They do all of the research and all of the work, and they deliver it to your insurance company. They are HIPAA-compliant, which means that your health information is as safe with them as it is at your doctor’s office.

Right now, Claimable is filing appeals for the following:

• migraines, extremely bad headaches that can last for hours or days
• medications for weight loss and Type 2 diabetes (GLP-1s)
• asthma and eczema, conditions that affect your breathing and your skin
• rheumatology and autoimmune diseases (Humira, Cosentyx, Enbrel, Dupixent, and many others), conditions where your body’s immune system attacks itself, causing pain and swelling
• PANS/PANDAS, rare childhood conditions where an infection causes the immune system to attack the brain

How much does it cost for them to file the appeal? For many people, there is no cost. In some situations, the cost is $39.95 plus shipping. That is insanely cheap for what you are getting! They do customized research on the medication, the science that backs up why you need it, your insurance company’s own policies about what they are legally required to provide, as well as state laws for why you should get the medication. It is impressive to say the least.

Now, if your insurance denial is for something other than these specific medications, you will need to appeal it on your own. Claimable is adding more and more appeal categories, so having them do your appeal may be available soon, but until that point, you’ll have to go at it alone. The bare minimum for sending an appeal is your Explanation of Benefits (EOB), the document insurance sends that explains how much they paid and how much you may owe, and a personal letter explaining your situation and why you need the medication or procedure. So, other than being time-consuming to research and file an appeal, are there other reasons that people don’t do it? Yes, another reason is that people don’t know their rights as a patient. That’s what I’m covering today, in Part 1 of knowing your rights to fight insurance denials.

The process is slightly different with each insurance company, so read the requirements they set forth. Yes, you will have to do a bit of research. Most likely you will need a copy of your EOB, which will provide the reason for your denial. When filing your appeal, it is absolutely essential to know the reason for your denial. The reason for the denial shapes the entire appeal process.

When I spoke with a physician, she said that appeals from patients count more than an appeal from a provider. I had to do some research because my doctors were always the ones submitting the appeals. The research showed that she was right. When you file an appeal, you have more rights than providers. The Affordable Care Act (ACA) grants patients strong appeal rights that go beyond the protections health providers can request on their behalf. This is specifically about filing the appeal yourself, rather than leaving it entirely to your provider’s office to handle.

5 Patient Appeal Rights to Fight Healthcare Denials

1) You are allowed multiple levels of patient appeals, including internal appeals, independent external reviews, judicial review, and regulatory complaints. By contrast, providers are only allowed internal appeals or payment disputes.

Insurance companies make a lot of mistakes or don’t follow the rules. That is the entire reason appeals exist. This is where you need to take action for yourself or a loved one. File a patient appeal with a supporting letter from your provider. If you get denied again, keep moving it to the next level for more chances to win your appeal. This is what the law states:

“Each health insurance issuer shall provide an internal claims appeal process and shall comply with the corresponding external review process,” meaning that if your appeal is denied from inside the insurance company, you have a right to have an external review, separate from the insurance company. (ACA, 42 U.S.C. § 300gg-19(a)-(b); ACA, 45 CFR § 147.136)

Many types of appeals can be submitted for external review. You can request an appeal after you’ve completed all of the internal appeals, if you disagree with the decision based on medical judgment. This is crucial. It can’t just be because you disagree. It must be that you disagree with the medical judgment they are making. That is why these are the types of appeals that can be taken to an external review.

• Medical necessity of care
• Appropriateness of care
• Health care setting
• Level of care
• Effectiveness of a covered benefit
• Experimental and investigational treatments

2) You have a right to have a qualified, human reviewer. Your appeal must be reviewed by a healthcare professional with the right expertise in treating your condition, and the reviewer is not supposed to be rewarded for denying your claim, or saying no.

This may sound strange, but more and more often, AI is being used to process claims. The other reason this is extremely important is that your doctor can end up in a peer-to-peer review, where your doctor talks to another doctor to determine whether your procedure is medically necessary, and the only requirement by the insurance company is that the doctor be some type of doctor. The doctor speaking to your doctor doesn’t have to be the type of specialist your doctor is. What does this mean? It means that you could need a complex pain management procedure, and the doctor your specialist talks to could be a pediatrician. I’m not exaggerating. It sounds crazy, doesn’t it? You have the law to back you up.

The reviewer should be a person with appropriate knowledge, who was not involved in the initial decision. (ACA, 42 U.S.C. § 300gg-19(b)(2)) The hiring, payment, termination, or promotion of the reviewer must not be made on the likelihood that the individual will support the denial of benefits. (ACA, 45 CFR § 147.136(b)(2)(ii)(D))

How gross is that, that it has to be written into a law? At least, you are now protected. To further protect yourself, ask your insurance company for the reviewer’s National Provider Identifier (NPI) to confirm your reviewer’s qualifications, meaning that the reviewer has the same qualifications as your provider, like the same specialty.

3) You have a right to hear the results of your appeal clearly and within a set timeframe.

Insurance companies must give you a written explanation for any denial, with appeal instructions, within these specific timeframes: 72 hours (3 days) for urgent needs or formulary exceptions, meaning prescriptions that are not on the insurance company’s approved medication list. They have 15 days for prior authorizations, when you have to get the insurance company to say “yes, we will pay for the procedure or prescription” before you get the procedure or medication. They have 30 days for medical services that have already been received.

This is what the law states:

“Your insurer must notify you in writing and explain why: within 72 hours for urgent care cases, within 15 days if you’re seeking prior authorization for a treatment, and within 30 days for medical services already received.” (healthcare.gov; 29 C.F.R. § 2560.503-1(f)(2))

Demand your denial notice in writing. It gives you the perfect roadmap for your appeal because the notice explains why you were denied and outlines your appeal rights. The denial notification must legally include an explanation of why it was denied in a way that you are able to easily understand: 1) the specific reason or reasons the claim was denied; 2) a reference to the specific part of your plan that the denial was based on; 3) a description of any additional information necessary for you to perfect, meaning to complete or strengthen, the claim and an explanation of why this information is necessary; and 4) a description of the plan’s review procedures and the time limits. The law says you need to be able to understand it, based on your culture and language, as well.

For external reviews, if the review is done by someone not part of your insurance company, the law is a little bit different.

“Standard external reviews are decided as soon as possible – no later than 45 days after the request was received. Expedited external reviews are decided as soon as possible – no later than 72 hours, or less, depending on the medical urgency, after the request was received.” (29 C.F.R. § 2560.503-1(f)(2))

When they talk about an expedited external review, they are referring to a situation that is serious and time-sensitive. A delay in care would harm the patient, so they rush to get the decision made. These external reviews are decided as soon as possible, but no later than 72 hours (3 days), or less, depending on how serious the situation is, after the request was received.

4) You have the right to have decisions based on scientific evidence.

The insurance company must determine the medical necessity of your treatment based on reliable scientific evidence and standards accepted by the medical community, not by an AI computer program. These decisions are extremely important because they determine whether you get the care you need and deserve. Their decisions should never be based only on cost or decided mindlessly.

How can you make sure this is happening?

I have to be honest with you. I didn’t know that this existed. If your insurance company is trying to override your doctor’s orders or ignore accepted standards, you can request your Summary Plan Description (SPD) to confirm whether they are following their own rules, and if they are not, you can challenge their decision. Now, I recognize that all of this takes time and energy that you may not have. That’s okay. I just want you to know your rights and how to stand up for yourself when it comes to fighting a denied claim.

I’ve been talking a lot about medical necessity. Medical necessity is exactly what it sounds like; it is when something is medically necessary. Interestingly, it is defined in your health insurance plan’s medical policy. (NAIC, What is Medical Necessity?) There may also be a definition that is found in state law. Here’s how it may be written into law:

• provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease; and except for clinical trials that are described within the policy, not for experimental, investigational, or cosmetic purposes;
• necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms;
• within the generally accepted standards of medical care in the community; and/or
• not solely for the convenience of the insured, the insured’s family, or the provider. In plain terms, you are the one with insurance, so you are “the insured.”

5) You have a right to a full and fair review.

The law says:

Your insurance company must “provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.” (ERISA, 29 CFR § 2560.503-1(h)(2)(iv); ACA, 42 U.S.C. § 300gg-19(a)(2)(A))

Insurance companies must do a complete and full review of all of the information submitted with an appeal.

The reviewer of your appeal must provide you with access to your claim. This is what the law says:

“[A]llow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process.” (ACA, 42 U.S.C. § 300gg-19(a)(1)(C))

What does this mean? Your insurance company must allow you to review your claim and must allow you to continue to receive coverage until the appeal process is complete. This can be extremely helpful and provide a window into what they used to make their decision. You can then use that information to appeal your claim.

Here’s the thing: of course you aren’t going to know your rights. Most people don’t have time to research their healthcare rights. It doesn’t occur to people to look into their rights until they are in a crisis, and then they are overwhelmed.

I’ve covered a lot of information. If this feels overwhelming, you don’t have to navigate this alone. Book your free 15-minute consultation with me here.

Definitions

Colorectal cancer: cancer that starts in the large intestine, which is also called the colon, or in the rectum, the last section before waste leaves the body

Radiation: a treatment that uses high-energy rays to target and kill the cancer

Chemotherapy: a treatment given to you by mouth or in your veins that uses very strong medications to kill the cancer

Clinical trial: a research study where doctors test new treatments on people to see if they are safe and effective

PET scan: a type of imaging that detects cancer activity and other diseases throughout the body

CT scan: a type of X-ray that creates detailed pictures of the inside of your body, which can detect solid tumors and other conditions

Morphine: a very strong prescription painkiller

Orthopedic surgeon: a doctor who specializes in treatment and surgery of bones and joints

MRI: a type of imaging that uses magnetic fields to create detailed pictures of soft tissues in your body, like the spinal cord, brain, and muscles

Oncologist: a doctor who specializes in cancer treatment

Adrenal gland: a small gland that sits above each kidney and makes hormones that help your body manage stress, blood pressure, and other important functions

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

HIPAA: a law that protects your personal health information from being shared without your approval

Migraine: a very bad headache that can last for hours or days

GLP-1: a type of medication for weight loss or Type 2 diabetes

Asthma: a medical condition that makes it hard to breathe

Eczema: a medical condition that affects the skin

Rheumatology: a branch of medicine that treats conditions that cause pain, swelling, and stiffness in the joints, muscles, and bones

Autoimmune disease: a disease where the cells that are supposed to fight off infections end up fighting your own body’s healthy cells

PANS/PANDAS: rare childhood conditions where an infection causes the immune system to attack the brain

Internal appeal: when your appeal is reviewed by someone inside your insurance company

External review: when your appeal is reviewed by someone not employed by your insurance company

Judicial review: when your appeal is reviewed by a judge

Regulatory complaints: a formal complaint filed with a government agency, like your state’s Department of Insurance, reporting that your insurance company broke the rules

Investigational treatment: a treatment that is still being studied and has not yet been proven effective for your specific condition

Peer-to-peer review: when your doctor speaks with another doctor directly to try to get your procedure approved

National Provider Identifier (NPI): the number that is specific to a provider that you can use to research their specialty, training, and qualifications

Formulary exception: when your insurance company agrees to cover a medication that is not on their approved medication list

Summary Plan Description (SPD): a document your employer or insurance company is required to give you that explains your health plan’s benefits, what is and is not covered, your costs, and your rights as a plan member

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

Enrollee: the person enrolled in the health plan

Claimant: the person who is filing or has filed an insurance claim

Frequently Asked Questions

What is the difference between a prior auth denial and an after-the-fact claim denial? A prior authorization denial is when your doctor has submitted a request for insurance to agree they will pay for your procedure or prescription before you receive either, and your insurance company denies the request. An after-the-fact claim denial is when the insurance company says they won’t pay after you’ve already had the service.

How do I know if I have the right to appeal? In most cases, you have a right to appeal any denial. The reason for the denial determines the type of appeal you qualify for.

Do Medicare and Medicaid have the same appeal rights as commercial insurance? Medicare and Medicaid both provide appeal rights; however, there are differences, including timelines and procedures.

What is Claimable and how does it work? Claimable is an AI platform that takes your health insurance claim denial, your insurance information, and some simple personal health details, and creates a well-researched, science-based insurance claim appeal.

Is my health information safe with Claimable? Yes. Claimable is HIPAA-compliant, meaning that your health information is as safe with them as it is with your doctor’s office.

What medications or conditions does Claimable cover?

• migraines
• medications for weight loss and Type 2 diabetes (GLP-1s)
• asthma and eczema
• rheumatology and autoimmune diseases (Humira, Cosentyx, Enbrel, Dupixent, and many others)
• PANS/PANDAS

How much does Claimable cost? For many, it’s completely free. In some cases, it costs $39.95 plus shipping.

What if Claimable doesn’t cover my medication or condition? In that case, unfortunately, you would have to file your own appeal.

What should I include in my appeal letter? You should include:

• your name
• insurance identification number
• your claim reference number
• medication/treatment
• date of denial
• the reason for denial
• your documented medical history
• any documented medical evidence that supports your appeal
• state or federal law that supports your appeal
• your diagnosis
• how it affects your life
• what your typical day looks like when you are at your worst
• what you can’t do or what causes you significant difficulty
• any prior treatments you’ve tried and failed
• why the medication/treatment is medically necessary, for example, what happens if you don’t get it or if you stop getting it

Can my doctor file the appeal for me, or do I have to do it myself? Your doctor can file the appeal for you; however, you, as the patient, have more levels of appeals available to you. These include an external review, a judicial review, and regulatory complaints. Providers filing on their own behalf are only able to dispute charges and have an internal review.

Can I appeal on behalf of a family member? Yes, as long as the patient has signed an authorization form with the insurance company that makes you their approved representative.

What happens if my external review is also denied? If your external appeal is denied, you can request a judicial review.

How do I find out if my reviewer is qualified? You can ask for the reviewer’s National Provider Identifier (NPI) that is unique to them, and from there, you can look up their qualifications. You can search their NPI here: npiregistry.cms.hhs.gov. Healthcare providers get their unique 10-digit NPIs to identify themselves in a standard way throughout their industry.

What if I miss the deadline to appeal? Unfortunately, if you miss the deadline, you miss the opportunity to appeal your claim. This is why it is extremely important to read your medical documents when you get them. If reading an EOB feels overwhelming, check out my blog post: What is an EOB and How Do I Read It? Finally Explained.

How long does the whole appeal process take? It depends on the appeal. 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 is a Summary Plan Description and how do I get one? A Summary Plan Description is a document that summarizes your insurance plan coverage. You can get this from your employer or from the insurance company itself.

Does ERISA apply to my plan? ERISA applies to any plan that is through your job, current or in retirement. ERISA, in general, does not apply to government plans, at the federal, state, and local levels, or church plans.

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.

Claimable. getclaimable.com. Accessed August 2026.

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

What Is Medical Necessity? National Association of Insurance Commissioners.

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