How to Appeal a Prior Authorization Denial for Your Medication

When your insurance denies coverage for a medication your doctor prescribed, it’s not just a paperwork hiccup-it’s a barrier to your health. You’re not alone. In 2024, prior authorization denials happened for 6% of all specialty drug requests in the U.S., and yet, only 11% of people even try to appeal. That’s a problem, because 82% of those appeals get approved when done right. This isn’t about fighting the system-it’s about knowing how to work it.

Understand Why Your Medication Was Denied

The first thing you need to do is read the denial letter. Not skim it. Read every word. Denials usually fall into three buckets:

• Incomplete paperwork (37% of cases): Missing forms, wrong IDs, or unsigned documents.
• Lack of medical necessity (48%): The insurer says your condition doesn’t meet their criteria for this drug.
• Not covered by your plan (15%): The medication isn’t on your plan’s formulary, or you didn’t try cheaper alternatives first.

Your denial letter should say exactly why. If it doesn’t, call your insurer. Ask for a written explanation. Don’t accept vague answers like “doesn’t meet criteria.” Push for specifics. You need to know what they’re saying before you can fix it.

Gather Every Piece of Medical Evidence

This is where most appeals fail. People send a letter and hope for the best. Winning requires proof. You need:

• Your doctor’s clinical notes showing your diagnosis and treatment history.
• Lab results or imaging reports that support the need for this medication.
• A letter from your prescribing physician explaining why this drug is medically necessary.
• Documentation of prior treatments that failed-names of drugs, dates, side effects, and outcomes.
• Any pharmacy records showing you tried and failed other medications.

For example, if you’re appealing for Humira and your doctor tried three other biologics over 10 months with no improvement, include that timeline. One patient on Reddit reversed a denial by attaching a two-page chart with exact dates and results. Insurers respond to facts, not pleas.

Follow the Exact Appeal Process for Your Insurer

Every insurance company has its own rules. You can’t guess. You must follow their procedure exactly.

• CVS/Caremark requires faxing your appeal to 1-888-836-0730 and includes your full name, ID, date of birth, drug name, and clinical info.
• UnitedHealthcare demands online submission through their provider portal.
• Kaiser Permanente allows appeals via phone, mail, or online, but requires a signed physician statement.

Check your insurer’s website or call their member services. Ask: “What is the exact process to file a prior authorization appeal?” Write it down. Then follow it step by step. Miss one detail-like forgetting your member ID-and your appeal gets tossed.

Write a Clear, Specific Appeal Letter

Your letter isn’t a request. It’s a clinical argument. Here’s the structure that works:

1. State your intent: “I am formally appealing the denial of [drug name] for [patient name].”
2. Quote the denial reason: “Your letter dated [date] denied coverage because [exact wording].”
3. Refute it with evidence: “This is incorrect because [clinical note, test result, or prior treatment failure].”
4. Reference their own policy: “According to your 2024 Formulary Guidelines, Section 4.2, this medication is covered for [diagnosis] when [criteria] are met.”
5. Include codes: Add the ICD-10 diagnosis code and CPT procedure code if relevant.
6. End with a clear ask: “Please approve coverage immediately and notify me in writing.”

A 2024 study from Keck Medicine found that appeals using this format had an 85% success rate. Why? Because they answered the insurer’s own objections before they even asked.

Get Your Doctor Involved

Your doctor’s letter isn’t optional-it’s critical. Insurers trust doctors more than patients. A direct clinical statement from your provider increases your chances by 32%.

Ask your doctor to write a letter that includes:

• Your diagnosis and why this drug is the best option.
• Why alternatives failed or aren’t suitable (e.g., side effects, allergies, ineffectiveness).
• How delaying treatment could worsen your condition.
• A reference to the insurer’s own clinical guidelines.

Many doctors are overworked, so give them a template. You can find free templates from the Obesity Action Coalition or the American Medical Association. Just fill in your details and ask them to sign it.

Track Everything and Follow Up

Don’t assume your appeal was received. Track it like a package.

• Keep copies of every document you send.
• Use certified mail with return receipt-or take screenshots if submitting online.
• Note the date you submitted and the reference number you were given.
• Call the insurer after 10 business days. Ask for the status and who is reviewing your case.
• If they say “it’s in process,” ask for the name of the reviewer and a direct phone number.

Seventy-eight percent of physicians say they had to call multiple times to get a response. Don’t give up. If you don’t hear back in 30 days, escalate. Ask to speak with a supervisor or the provider relations department. They resolve 76% of submission issues.

Know Your Rights and Next Steps

If your appeal is denied again, you have more options:

• External Review: You have 365 days from your final denial to request an independent third-party review. This is your legal right under the Affordable Care Act.
• Medicare Advantage: If you’re on Medicare Advantage, your appeal success rate is 22% higher than commercial plans. Use that advantage.
• State Insurance Commissioner: If your insurer is unresponsive or violates state laws, file a complaint with your state’s insurance department.
• Independent Dispute Resolution (IDR): If your medication costs over $500 and was denied under the No Surprises Act, you can trigger an IDR process-but only 0.3% of people do.

Don’t wait until you’re out of medication. Start the external review process as soon as your second denial comes in.

What to Avoid

These mistakes kill appeals:

• Waiting too long: You have 180 days from the denial date to appeal. Miss that, and you lose your right.
• Not including codes: 89% of approved appeals include correct ICD-10 and CPT codes. If you don’t know them, ask your doctor’s office.
• Using emotional language: “I can’t afford this” won’t help. “This drug is the only one proven effective for my condition” will.
• Trying to appeal without documentation: One patient on Reddit failed because they didn’t include the CPT codes mentioned in the denial letter. That’s an easy fix-don’t make it.

How Long Does It Take?

For employer-sponsored plans covered by ERISA, insurers must respond within 60 days. For Medicare Advantage, new rules require a decision within 72 hours. Most insurers take 14-30 days. But if you’re tracking and calling, you can often get a decision in 7-10 days.

One patient got their Humira approved in just 7 business days after submitting a detailed timeline of failed treatments. Another waited 45 days because they sent the appeal to the wrong department.

Why This Matters

This isn’t just about getting a pill. It’s about your health. In 2023, 79% of doctors said patients abandoned treatment because of prior authorization delays. Some got sicker. Some ended up in the hospital. Others paid out of pocket and went into debt.

Appealing isn’t just paperwork. It’s advocacy. You’re not just fighting for a drug-you’re fighting for your right to timely, appropriate care.

And the data is clear: if you do it right, you win.