Insurance Prior Authorization Denied: How to Appeal and Get Approval

Insurance Prior Authorization Denied: How to Get It Approved

Prior authorization (prior auth, PA, or precertification) is the process by which your health insurance company must approve certain treatments, medications, or procedures before they are provided. When your insurer denies a prior authorization request, the treatment you need — and your doctor has prescribed — is suddenly on hold.

The good news: prior authorization denials are among the most frequently overturned insurance decisions. A 2022 KFF analysis found that 82% of denied prior authorization appeals in the ACA marketplace were overturned. The key is knowing which tools to use and moving quickly.

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What Prior Authorization Covers and Why Denials Happen

Insurers require prior authorization for a wide range of treatments, including:

• Specialty medications (biologics, brand-name drugs, specialty injectables)
• Elective or complex surgical procedures
• Advanced imaging (MRI, CT, PET scans)
• Specialty care referrals
• Durable medical equipment
• Mental health and substance use treatment (residential, intensive outpatient)
• Home health services
• Inpatient hospital stays beyond a certain number of days

Common denial reasons:

• Step therapy required: Insurer requires you to try and fail a cheaper alternative first ("fail first" requirements)
• Not medically necessary: The insurer's clinical guidelines don't support the treatment
• Experimental or investigational: Treatment not yet approved under their criteria
• Benefit not covered: The specific treatment is excluded from your plan
• Administrative: Missing information, expired PA, or coding issues

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Step 1: Understand Exactly Why the Prior Auth Was Denied

Your insurer must provide a written denial that includes:

• The specific reason for the denial
• The clinical guideline or coverage policy used
• Instructions for appealing the decision

If any of this information is missing, call your insurer and request it in writing. Under ACA regulations, insurers must provide clear denial notices for prior authorization decisions.

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Step 2: Your Physician's Peer-to-Peer Call (The Fastest Solution)

The single most effective first step for prior authorization denials is a peer-to-peer review — a direct phone call between your treating physician and the insurer's medical director who reviewed the denial.

During the peer-to-peer call, your doctor can:

• Present your specific clinical case directly
• Explain why the standard clinical guidelines support this treatment for your situation
• Provide additional clinical context not captured in the prior auth request
• Challenge the insurer's medical reviewer's interpretation in real time

How to request a peer-to-peer:

• Your physician (not you) calls the insurer's provider services line
• Ask specifically for a peer-to-peer review with the medical director who reviewed the case
• Peer-to-peers are typically available for 1–3 business days after the denial
• The insurer must make a decision on the same call or within 24–48 hours afterward

Results: Multiple studies and physician surveys indicate that peer-to-peer reviews result in authorization reversal approximately 50–70% of the time for clinical necessity denials.

If your physician's office is not pursuing a peer-to-peer, advocate strongly for this step. It is their most powerful and fastest tool.

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Step 3: File a Formal Appeal

If the peer-to-peer doesn't result in approval, file a formal written appeal. Under ACA rules, you have 180 days from the denial notice to file an internal appeal, though your plan may require a shorter timeframe — check immediately.

What Your Appeal Should Include

From your physician:

• A detailed letter of medical necessity explaining:
  • Your specific diagnosis and clinical history
  • Why this specific treatment is indicated for your case
  • Why alternative treatments are inappropriate, less effective, or have been tried and failed
  • The clinical consequences of not receiving this treatment
• Any supporting clinical notes, test results, or imaging reports

From you:

• A formal appeal letter requesting reversal of the denial
• Documentation of any step therapy you've already completed
• Documentation of prior treatments tried and their outcomes

Clinical evidence:

• Treatment guidelines from relevant specialty societies (ACS, ACC, APA, etc.)
• Published clinical studies supporting the treatment's efficacy
• FDA approvals and indications for the treatment

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Step 4: Request Expedited Review for Urgent Cases

If waiting for the standard 30-day appeal timeline would seriously jeopardize your health, request an expedited appeal. Criteria:

• Your life or health would be seriously jeopardized by delay
• You need the treatment urgently and standard timelines are medically inappropriate
• Your physician certifies the urgency in writing

Expedited appeal timelines:

• Insurer internal expedited appeal: 72 hours decision
• External expedited review: 72 hours decision

You can request expedited external review simultaneously with an expedited internal appeal — you don't have to wait for the internal process to complete.

For hospital-based situations — such as a prior auth being denied while you are admitted — you may also be entitled to concurrent care protections that require the insurer to continue approving care while the appeal is pending.

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Step 5: Challenge Step Therapy Requirements

Step therapy (or "fail first") requirements — where the insurer requires you to try a cheaper drug or treatment before approving the prescribed one — can be challenged if:

• You have already tried the required alternative and it failed or caused adverse effects
• The required alternative is medically inappropriate for your specific condition
• A significant portion of states now have step therapy exception laws that require insurers to grant exceptions when clinically indicated

As of 2024, over 30 US states have enacted step therapy exception laws. Check your state's requirements and specifically request a "step therapy exception" if your case qualifies.

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Step 6: External Review

After exhausting internal appeals, request free independent external review under the ACA. For prior authorization denials involving medical necessity, this is particularly effective:

• Submit all clinical evidence to the IRO
• Have your physician write a specific letter to the IRO (different from their internal appeal letter — more detailed, more clinical)
• Include peer-reviewed literature supporting the treatment
• The IRO must decide within 45 days (or 72 hours for expedited)

The 82% overturn rate cited earlier from KFF data applies to ACA marketplace plans specifically — suggesting that when policyholders actually appeal, prior auth denials are frequently wrong.

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State-Level Protections

Many states have enacted additional prior authorization reforms beyond federal ACA minimums:

• California: SB 1018 (2018) limits insurer ability to require prior auth for ongoing, already-approved treatments
• Texas: HB 2466 limits prior auth requirements for certain established treatment plans
• Virginia, Michigan, and others: Gold carding laws that exempt physicians with high approval rates from some PA requirements

Contact your State Department of Insurance to understand the specific prior auth protections in your state.

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Common Mistakes When Fighting Prior Auth Denials

1. Waiting for your physician to initiate the appeal without following up. Physicians' offices are busy. Confirm with your doctor's office that they have initiated both the peer-to-peer request and the formal appeal.

2. Not documenting the step therapy failure. If you've tried the required alternative and it didn't work, document this thoroughly — dates, doses, adverse effects, lab results.

3. Missing the peer-to-peer window. Peer-to-peers must typically be requested within days of the denial. Don't wait.

4. Submitting a generic letter of medical necessity. The physician's letter should be specific to your clinical situation, not a generic statement that the treatment is "medically necessary." It should address every specific criterion in the insurer's coverage policy.

5. Not checking for state step therapy exception laws. If your state has these protections and you qualify, this is a specific, powerful ground for overriding a step therapy requirement.

6. Giving up after the first denial. Internal appeal overturn rates are significant. External review overturn rates are substantial. Most people who are denied stop after the first rejection — but the data shows that persistence wins.

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When to Involve Your State Insurance Commissioner

File a complaint with your State Department of Insurance if:

• The insurer missed appeal decision deadlines
• The denial notice was inadequate or missing required information
• The insurer is applying step therapy requirements that violate state law
• The denial appears to violate mental health parity requirements

State insurance regulators can intervene directly with insurers and often produce faster resolution than the formal appeal process.

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Getting Your Appeal Letter Written

A strong prior authorization appeal letter needs to address the insurer's specific clinical criteria directly and present your physician's case compellingly. ClaimBack can generate a structured, evidence-based prior authorization appeal letter tailored to your specific denial reason and treatment type. Visit claimback.app to get your letter ready quickly.

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Summary: Prior Authorization Denial The Full Fight

1. Obtain the written denial with specific clinical criteria cited
2. Have your physician request a peer-to-peer call within days of denial
3. File a formal written appeal within 180 days (often sooner — check immediately)
4. Request expedited appeal and external review if the situation is medically urgent
5. Challenge step therapy requirements if you've tried alternatives or state law provides exceptions
6. Request free external review after internal appeals are exhausted
7. File a state insurance department complaint for procedural violations