What Are Appeals, and How Do I File One?

• A specific medication is not in its formulary.
• A service requested by a healthcare provider is not deemed medically necessary or is considered experimental or investigational for your condition.
• You are not eligible for the benefit requested under your healthcare plan.
• No pre-authorization was submitted.

“You should appeal when your health insurance denies care, treatment, or coverage that your doctor says you need, and you believe the denial is wrong or unjust,” says Alicia Graham, an adviser and cofounder of Claimable, an AI-powered platform that helps patients appeal insurance denials.

“Insurance companies often get it wrong, whether it’s through automation, rushed decisions, or just failing to follow the rules. That’s exactly why the appeals process exists,” she says. “If you get a denial and think, ‘This can’t be right,’ that’s your cue to appeal.”

The denial letter from your insurer will be your road map to filing an appeal. Ask for your denial notice in writing if you don’t already have it. The notice, often called a Notice of Adverse Benefit Determination or Explanation of Benefits (EOB), reveals why you were denied and outlines your rights to appeal.

“Unfortunately, this happens far more often than it should,” says Graham. “If your insurer stalls, you need to report it to your regulator,” which is typically the state or federal agency that oversees your health insurer or employer plan. This may be your state’s insurance agency if you purchased a plan through the Health Insurance Marketplace or the U.S. Department of Labor for self-insured employer-sponsored plans.

Write Your Appeal Letter

Next, write and submit your appeal. In the letter, explain why you believe the denial was wrong, what treatment you need, and why it’s medically necessary. Include any relevant background or history, especially if you’ve tried other treatments. Also ask your doctor to write a supporting letter, since their clinical judgment carries weight. “What matters most is that it’s honest, direct, and backed by medical facts,” says Graham.

Request Your Claim File

Many people aren’t aware that they should ask their insurer for their claim file, which includes all the documents, emails, call logs, and internal notes used to make the decision. “Legally you’re entitled to see it, and it’s one of the most powerful tools you have to spot mistakes and strengthen your case during the appeals process,” says Graham.

To access your claim file, send a written request and follow up by phone if necessary. If your insurer doesn’t respond within 30 days, file a complaint with the agency that regulates it.

Internal vs. External Review

There are two types of appeals: an internal review and an independent, or external, review. In an internal review, you have up to 180 days (or about six months) to file the appeal, says Teri Dreher Frykenberg, RN, a patient advocate and the founder of Nurse Advocate Entrepreneur based in Monson, Massachusetts. If you have already received the medical service, your insurer must respond within 60 days. If you haven’t received the service yet, it must respond within 30 days.

“Sometimes your well-being or even your life is contingent on getting a prompt appeal; if so, you can request an expedited process,” she says. Your plan must make a decision on an urgent appeal within four days.

If your internal appeal is denied, your plan must give you instructions on how to request an independent, external review. If you have an urgent situation, you can ask for an external review at the same time as your internal appeal. You have four months from the time your insurer denies your internal appeal to file for an external review.

Keep Copies and Follow Up

Before you submit your appeal, make copies of everything. Mark your calendar to follow up, and if you don't hear back within the mandated time frame, escalate the issue to regulators if needed, says Graham. At the end of the internal appeals process, your insurer must provide you with a written decision and instructions on how to file an external review.

You don’t have to go through the appeals process alone. Your healthcare provider can be a powerful ally: Ask your doctor or their staff to help with your appeal, such as by writing a detailed letter explaining the medical necessity of the treatment or service.

You can also consider contacting a patient advocacy service that specializes in helping patients navigate insurance denials and appeals. Many hospitals have patient advocates or financial counselors who can assist, says Neal Shah, chairman of Counterforce Health, a free platform offering AI tools and resources to help patients appeal denied health insurance claims. Patient advocacy organizations like the Patient Advocate Foundation also offer free assistance to navigate the appeals process. State insurance departments can intervene in cases of improper denials.

• 4 business days for an urgent appeal
• 30 days for standard reviews for a service you haven’t yet received
• 60 days for a service you have received

External reviews performed by an independent expert, not your insurance company, can take up to 45 days, but if it’s an urgent review, it can take no longer than 72 hours. “If you have to go through [the entire process of] second-level appeals, external reviews, et cetera, it can take three to six months,” says Evan Nadler, MD, a child and adolescent bariatric surgeon in Washington, DC. “I remember one case of mine finally getting approved after a year of my fighting,”

If your health insurance appeal is rejected, don’t stop there. One or even two denials doesn’t mean you’re out of options.

“The law gives you the right to multiple levels of patient appeals, including internal appeals through your insurance company, independent external reviews by third-party medical experts regulatory complaints filed with your state insurance department or federal agencies, and legal action in local or federal courts,” says Graham.

• Medical judgment issues, such as the determination that something is medically necessary
• Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information on your application
• Experimental or investigational treatment determinations

Some states have broader criteria for external review eligibility, however.

The external review process gives you access to an independent review organization (IRO) that will examine your case without bias toward the insurance company. The reviewers typically include medical professionals who can evaluate the clinical aspects of your case, says Shah.

External review decisions are binding on the insurance company. If the external reviewer overturns the denial, your insurer must comply with this decision and provide coverage. But if the external reviewer upholds the denial, you may still have other options, such as pursuing legal action.

• Your doctor’s name and contact information
• Your health insurance policy number
• Specifics about what was denied, why, and when
• A compelling story that makes it harder to deny your appeal
• A letter from your doctor including information about prior treatments, why he or she is requesting the treatment or medicine, and whatever other information will help state your case

It’s important to be very clear about why you need the desired medical service or medication and why you believe it should be covered. Keep a copy of the letter and any documents you send. If you’re looking for further letter-writing guidance, the Patient Advocate Foundation’s Sample Appeal Letter for Denied Claim and Sample Appeal Letter for Pre-Authorization Denial may help. Other examples are available online from organizations that provide patient advocacy services, such as CounterForce Health’s appeals letter tips and template.

While the appeals process may feel like an exhausting battle, it’s important to stay organized and follow through until you get a fair resolution.

“I’ve worked on hundreds of appeals, and what stays with me are the stories behind them: people stuck in limbo, waiting for care they urgently need,” says Graham. “I’ve seen firsthand how a single appeal can be life-changing or lifesaving. The bottom line: Appeal. The system is built on the assumption that you won’t. But you have rights, and you deserve care. You’re not asking for a favor. You’re asking for what’s fair.”