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, depending on your health plan and the reason for the denial, 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. Many plans provide at least 180 days to file an internal appeal, but deadlines vary by plan and type of coverage, so use the deadline in your notice.

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 whether the office can help appeal the denial and provide documentation explaining why the care is medically necessary.

Your doctor’s office may already have experience appealing this particular insurer or type of denial. Ask for supporting documentation such as 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 for the specific reason the care was denied, the process and deadline for appealing the decision, and 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.

If external review rights apply, your final internal denial should explain how to request that review.

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, and 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 whether your health plan is fully insured or self-funded.

Self-funded employer plans are generally governed primarily by federal law and may fall under the U.S. Department of Labor’s Employee Benefits Security Administration. Fully insured employer plans are generally subject to state insurance regulation as well as applicable federal requirements.

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, a Consumer Assistance Program where available, 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.