Prior Authorization Denied: How to Appeal Your Insurance Decision

Your insurer denied your prior authorization request. Now you're stuck: the treatment is approved, the provider is ready, but the authorization won't clear. This guide shows you exactly how to appeal, including expedited options for urgent cases.

Prior authorization denials are often based on incomplete information or overly conservative medical criteria. Most appeals succeed because the insurer sees more complete medical information the second time.

Here's how to get approval fast.

What Is Prior Authorization?

Prior authorization (prior auth, pre-approval) is the insurer's way of saying: "Before you get this treatment, we need to approve it."

Why insurers require it: To manage costs. The insurer reviews whether the treatment meets their criteria for medical necessity and cost-effectiveness.

Why it matters: Without approval, the provider might not treat you, or you might face huge bills.

Key point: Prior auth denial is NOT the same as a claim denial. It's a pre-treatment decision. This matters because you still have time to fix it before treatment happens.

Types of Prior Authorization Denials

Urgent/Expedited Denial

The insurer denied your request for urgent treatment. You needed approval within 72 hours and didn't get it.

Examples: Emergency surgery, urgent imaging, rapid-access specialist visit.

Appeal process: Expedited. You can usually get a decision within 24-48 hours.

Standard Denial

The insurer denied your request for non-urgent treatment. They reviewed and said no.

Examples: Elective surgery, ongoing therapy, certain medications.

Appeal process: Standard. Usually 30 days for review.

Incomplete Information Denial

The insurer said no because they didn't have enough information. (This is actually good news—it often means "maybe" not "definitely no.")

Examples: Missing medical records, no clinical justification letter, incomplete documentation.

Appeal process: Resubmit with complete information. Often approved on resubmission.

Why Prior Auth Denials Happen

Reason 1: Insufficient Medical Information The insurer didn't have complete records. Your doctor submitted bare-bones information. The reviewer couldn't see the full picture.

Solution: Resubmit with complete medical records, doctor's letter of medical necessity, clinical guidelines.

Reason 2: Conservative Medical Criteria The insurer's criteria are stricter than standard medical practice. They approved treatment for the same condition last year, but their criteria tightened.

Solution: Show current clinical guidelines, cite recent approvals for similar cases, request peer-to-peer review.

Reason 3: "Not Medically Necessary" Finding The insurer determined the treatment doesn't meet their medical necessity standard.

Solution: Same as reason 2—cite guidelines, get doctor's letter, request peer-to-peer review.

Reason 4: Cost Considerations The insurer thinks the treatment is too expensive. (They can't say this directly, but it's often the real reason.)

Solution: Show the treatment is standard of care, cite guidelines, show cost-effectiveness if possible.

Reason 5: Missing Authorization Request Your provider never submitted the request properly. You're waiting for approval that was never actually filed.

Solution: Contact the provider. Ask if they submitted. If not, submit immediately yourself.

Step 1: Understand the Denial

Your insurer must send you a written denial with specific reasons. Read it carefully.

Look for:

• What specific information was lacking?
• What specific medical criteria weren't met?
• Is there a number to call for more details?
• What's the appeals process and deadline?

If vague, call the insurer: "Can you explain in more detail why the prior auth was denied?"

Write down what they tell you. You'll address this specifically in your appeal.

Step 2: Assess Urgency

Is this urgent or standard timeline?

Urgent = get treatment within days: Request expedited appeal. Insurer has 24-72 hours to respond. Urgent appeals are faster.

Standard = get treatment within weeks or months: Standard appeal. Insurer has 30 days.

If urgent, say so in your appeal: "This patient requires treatment by [date] due to [medical reason]. Expedited review requested."

Step 3: File Your Appeal Immediately

Don't wait. File your appeal the same day or next day.

How:

1. Call the insurer's appeals department
2. State: "I am appealing the prior authorization denial dated [date]"
3. Provide: patient name, policy number, claim reference, treatment description
4. Request expedited review if urgent
5. Ask where to send supporting documentation
6. Confirm submission method (email, fax, mail)
7. Get a reference number for your appeal

Follow up in writing: Send a formal appeal letter with supporting documentation by mail and email (with read receipt).

What to Include:

• Your basic information (name, policy number, claim number, date of birth)
• Clear statement: "I am appealing prior authorization denial dated [date]"
• Treatment description and reason
• Doctor's name and contact information
• Why you disagree with the denial (address the specific reason given)
• Any new medical documentation
• Request for expedited review if urgent
• Signature and date

Step 4: Gather Supporting Medical Evidence

This is where appeals succeed. Add the information that was missing or incomplete before.

Get from your doctor:

• Detailed letter explaining why the treatment is medically necessary for your condition
• Your diagnosis and clinical findings
• Why this treatment is appropriate
• When treatment needs to happen (if urgent)
• Specialist opinion (if applicable)

Clinical guidelines:

• Print relevant guideline passages showing the treatment is standard of care
• Specialty society recommendations
• Evidence-based medicine references
• Industry standards

Medical records:

• Complete medical history for this condition
• Test results showing condition severity
• Proof of prior treatments (if relevant)
• Documentation of current symptoms

Comparative cases:

• If your insurer has approved the same treatment before (if you know of examples)
• Evidence of how the insurer treats similar cases

The stronger your documentation, the more likely approval.

Step 5: Request a Peer-to-Peer Review

For medical prior auth denials, request a peer-to-peer review.

What it is: Your doctor talks directly to the insurer's medical reviewer.

Why it works: Most prior auth denials happen because the insurer's reviewer didn't have complete information or misunderstood the case. A direct conversation with your doctor often immediately reverses the decision.

How to request: In your appeal letter: "I request a peer-to-peer review between [your doctor's name] and the insurer's medical director. My physician is available [specific times/dates]."

Provide your doctor's direct phone number. Encourage them to take the call. Many prior auths are approved within 24 hours of this conversation.

Step 6: Appeal to External Review (If Needed)

If the insurer denies your appeal (or doesn't respond in time), you can escalate to external review.

External reviewers:

• Vary by country and insurance type
• Independent of the insurer
• Can overturn the prior auth denial
• Often faster than internal appeals (72 hours for urgent)

In the USA:

• For ACA plans: independent review organization (IRO)
• For employer plans: ERISA external review
• For Medicare: Appeals Council
• For Medicaid: State-specific process

Timeline: Urgent cases: 24-72 hours. Standard: 30 days.

Contact your state insurance commissioner's office or your regulator for external review instructions.

What Evidence Wins Prior Auth Appeals

Organize your evidence strategically:

Priority 1: Doctor's Letter The most important document. Your doctor explaining the medical necessity in detail.

Priority 2: Clinical Guidelines Passages from NCCN, ASCO, or specialty society guidelines supporting the treatment.

Priority 3: Complete Medical Records All records the insurer might not have had before.

Priority 4: Specialist Opinion If applicable, letter from specialist supporting necessity.

Priority 5: Cost Evidence If cost is a factor (though insurers rarely admit this), show the treatment is cost-effective.

Common Prior Auth Denial Patterns

Pattern 1: "Missing Information" The insurer says they don't have enough records. Resubmit with complete records and doctor's letter. Often approved immediately.

Pattern 2: "Treatment not medically necessary" The insurer says your condition doesn't warrant this treatment. Counter with: clinical guidelines, doctor's letter, specialist opinion, disease severity evidence.

Pattern 3: "Alternative treatment available" The insurer suggests a cheaper option. Challenge with: your doctor's explanation of why the alternative won't work for you, side effects you've experienced with the alternative, specialist opinion supporting the requested treatment.

Pattern 4: "Fails our criteria" The insurer's criteria don't match your situation. Get your doctor's letter explaining your specific circumstances and why criteria should be waived in your case.

Pattern 5: "Investigational/Experimental" The insurer says the treatment is unproven. Show: FDA approval (if applicable), published clinical trials, clinical guidelines including the treatment, evidence of widespread clinical use.

Timing for Prior Auth Appeal

Urgent prior auth denial:

• Appeal immediately
• Request 24-48 hour expedited review
• If denied at internal level, request 72-hour external review
• Total time possible: 3-5 days to get approval

Standard prior auth denial:

• Appeal within 1 week
• Internal review: 30 days
• If denied, external review: additional 30 days
• Total: 2 months worst-case, often much faster

Insurance Companies Often Approve on Appeal

Here's the secret: insurance companies often deny on first request to see if you'll go away.

When you appeal with complete information, they frequently approve because:

• The information shows medical necessity clearly
• They realize their initial denial was too hasty
• Regulators track how often appeals are successful, and high denial rates trigger investigation

Most prior auth appeals succeed. Don't give up.

Writing Your Winning Prior Auth Appeal

Structure it:

Paragraph 1: "I am appealing the denial of prior authorization for [treatment] dated [date] for [patient name]."

Paragraph 2: "This treatment is medically necessary because [doctor's clinical reasoning]."

Paragraph 3: "The treatment is supported by clinical guidelines: [guideline reference]. [Quote from guideline]."

Paragraph 4: "My treating physician is prepared for a peer-to-peer review and can be reached at [phone number]."

Paragraph 5: "I request [expedited/standard] review. The treatment is needed by [date] due to [urgency]."

Attachments: Doctor's letter, guideline passages, complete medical records, specialist opinion (if applicable).

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Pre-Appeal Checklist

• I have the prior auth denial letter
• I know whether the appeal is urgent or standard timeline
• I have contacted my doctor for a detailed medical necessity letter
• I have researched clinical guidelines supporting the treatment
• I have my complete medical records
• I know the insurer's appeals department contact information
• I have a reference number for the original prior auth request
• I understand whether I can request expedited review
• I have arranged for my doctor to be available for peer-to-peer review if needed

Most prior auth denials are overturned on appeal. Push back.

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Disclaimer: ClaimBack provides AI-generated appeal assistance for informational purposes only. ClaimBack is not a law firm and does not provide legal advice. Always review your appeal letter before sending and consider professional advice for complex or high-value claims. Regulatory processes vary — always verify current procedures with your insurer or regulator.

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