Health Insurance Denied Your Care? Here’s How to Appeal
If your health insurance company denied a treatment, medication, procedure, scan, or other medical care your doctor recommended, the denial does not necessarily end the conversation.
You have the right to know why your care was denied. In many cases, you also have the right to appeal the decision and, if the insurer continues to deny coverage, request an independent external review.
The problem is that none of this tends to arrive with a friendly instruction manual.
Here’s where to start.
1. Get the denial in writing
Your insurer should provide an Explanation of Benefits, denial letter, or other written notice explaining its decision.
Do not rely only on what someone tells you over the phone.
Find the specific reason for the denial. Common reasons include:
The insurer says the treatment is not medically necessary.
The treatment requires prior authorization.
The service or medication is excluded from your plan.
The provider is out of network.
The insurer says the treatment is experimental or investigational.
The claim contained incorrect or incomplete information.
The reason matters because it determines what you need to challenge.
2. Find your appeal deadline
Your denial notice should explain how to appeal and when your appeal must be submitted.
Do not assume you have months to deal with it. If your health could be seriously harmed by waiting through the normal appeal process, ask whether you qualify for an expedited or urgent appeal.
3. Call your doctor’s office
Tell the clinician who ordered the care that your insurance company denied it.
Ask:
“Can you help me appeal this denial and provide documentation explaining why this care is medically necessary?”
Your doctor’s office may already have experience appealing this particular insurer or type of denial.
Ask them for supporting documentation such as your medical records, test results, treatment history, clinical notes, and a letter of medical necessity.
4. Call your insurance company
Use the number on your insurance card or denial notice.
You are trying to establish exactly what happened and exactly what needs to happen next.
Ask:
“What is the specific reason this care was denied?”
Then:
“What is the process and deadline for appealing this decision?”
If prior authorization is involved, ask whether the insurer needs additional documentation from your clinician.
Write down the date and time of the call, the name of the representative, any reference number they give you, and what they tell you to do next.
You are creating a paper trail.
5. Build your appeal
Your appeal should directly address the insurer’s stated reason for denying care.
Include the denial notice, a concise explanation of what you are appealing, relevant medical records, and supporting documentation from your clinician.
Your doctor’s letter should explain why the treatment or service is medically necessary and why alternatives required by the insurer may be inappropriate, ineffective, or potentially harmful in your particular situation.
Keep copies of everything you submit.
6. If they deny the appeal, ask about external review
Losing an internal appeal does not always mean you’re finished.
Depending on your health plan and the type of denial, you may be entitled to an external review, where an independent third party reviews the insurer’s decision.
Your denial or appeal decision should explain whether external review is available and how to request it.
7. Find out what kind of insurance plan you have
This matters more than most people realize.
Employer-sponsored plans may be fully insured or self-funded. Different laws, regulators, and appeal procedures can apply depending on the type of plan you have.
If you receive insurance through an employer, ask the benefits administrator:
“Is my health plan fully insured or self-funded?”
For some employer-sponsored plans, the U.S. Department of Labor may be an important resource. For others, your state insurance department may have jurisdiction.
8. Get outside help if you’re stuck
You do not have to understand the entire American healthcare bureaucracy before you’re allowed to ask for help.
Depending on your situation, useful resources can include your state Department of Insurance, the U.S. Department of Labor’s Employee Benefits Security Administration, HealthCare.gov, and nonprofit patient-navigation organizations.
The important thing is not to confuse “denied” with “there is nothing else I can do.”
Sometimes there is.
Keep a record of everything
Create one folder for the dispute.
Keep your denial notices, Explanation of Benefits documents, medical records, letters, emails, appeal submissions, confirmation numbers, names of representatives, dates of phone calls, and notes about what you were told.
Insurance disputes have an irritating habit of becoming archaeology projects.
Make yours easy to excavate.
Want to understand why patients have to do all of this?
We the Patients: Understanding, Navigating, and Surviving America’s Healthcare Nightmare explains how insurance, hospital billing, prior authorization, medical debt, consolidation, and other forces turned getting sick in America into an administrative job nobody applied for.
Sources and additional help
For current information about health insurance appeals and external review, consult HealthCare.gov, the Centers for Medicare & Medicaid Services, the U.S. Department of Labor’s Employee Benefits Security Administration, your state Department of Insurance, and your health plan documents.
Need more help?
For free insurance-appeal guides, tracking tools, state-specific information, and one-on-one navigation, visit Triage Cancer’s Appeals Resources.
Last reviewed: August 2026
This guide provides general educational information and is not legal, medical, or insurance advice. Insurance rules, appeal rights, deadlines, and procedures vary by plan and jurisdiction.
