How to Appeal a Prior Authorization Denial for Your Medication

When your doctor prescribes a medication and your insurance says no, it’s not just frustrating-it can be dangerous. You might be staring at a denial letter, confused about what to do next. But here’s the truth: prior authorization denials are often overturned. In fact, 82% of appeals succeed when done right. That means if your medication was denied, you still have a real shot at getting it covered. You just need to know the steps.

Understand Why It Was Denied

The first thing you need to do is read the denial letter. Not skim it. Read it carefully. Insurance companies don’t deny requests randomly. They give a reason, even if it’s buried in fine print. The most common reasons? Missing paperwork (37%), the insurer doesn’t think it’s medically necessary (48%), or the drug isn’t on their approved list (15%). If the letter says something vague like “insufficient documentation,” that’s your clue. It’s not a final no-it’s a request for more. Look for specific codes: ICD-10 diagnosis codes, CPT procedure codes, or the exact name of the drug. If those aren’t there, you’re missing key evidence. Don’t assume you know what they mean. Call your doctor’s office. Ask them to explain the denial reason in plain language. Most offices have staff trained to decode these letters. They’ve seen this before.

Gather Every Piece of Paper

You can’t appeal with hope. You need proof. That means collecting everything your doctor has on file related to your condition and treatment history. Start with:

• Your full name, date of birth, and insurance ID number
• The exact name of the denied medication (including dosage and form-tablet, injection, etc.)
• Medical records showing your diagnosis
• Lab results, imaging reports, or specialist notes
• Notes from your doctor explaining why this drug is necessary
• Proof of prior treatments that failed

This last point is critical. If you’ve tried two other drugs and they didn’t work-or made you sick-document that. The Obesity Action Coalition found that 63% of successful appeals include a clear timeline of failed alternatives. Include dates, names of drugs, and what happened. Did you get a rash? Did your symptoms get worse? Write it down. Your doctor should provide a letter of medical necessity. This isn’t a form letter. It needs to say: “This patient has [condition]. Standard treatments failed. This specific medication is the only clinically appropriate option.” If they just sign a template, it won’t work. Ask them to personalize it.

Follow the Insurer’s Rules Exactly

Every insurance company has its own process. CVS/Caremark wants appeals sent by fax. UnitedHealthcare requires online submissions through their portal. Humana may require a form you download from their website. Get the instructions from their website or call their member services. Don’t guess. You have 180 days from the denial date to file an appeal. That sounds like plenty of time-but delays happen. Start right away. If you wait, you risk missing the deadline. And once that window closes, your only option is an external review, which takes longer and has stricter rules. When you submit, keep a copy of everything. Send it certified mail if you can. If you’re using an online portal, take a screenshot of your submission confirmation. Write down the date, time, and name of the person you spoke with. Paper trails save lives.

Write a Clear, Specific Appeal Letter

Your appeal letter isn’t a complaint. It’s a clinical argument. Use this structure:

• State your intent: “I am formally appealing the denial of [drug name] for [your name].”
• Reference the denial letter: “Your letter dated [date] denied coverage because [reason].”
• Address each point directly: If they said “lack of medical necessity,” show them why it is necessary. Use your doctor’s letter and test results.
• Include all required codes: ICD-10, CPT, NDC numbers. If they’re missing, your appeal gets rejected before it’s reviewed.
• End with a request: “I respectfully request approval of this medication as medically necessary.”

Don’t write a novel. Be concise. Stick to facts. A 2-page letter with clear evidence beats a 10-page emotional plea every time. One patient on Reddit reversed a Humira denial in seven days by attaching a two-page timeline of failed treatments. Another lost their appeal because they didn’t include the CPT code mentioned in the denial. Details matter.

Get Your Doctor Involved

Your doctor isn’t just a signer of forms-they’re your strongest ally. Insurers listen to doctors more than patients. A call from your provider’s office can move the needle. Ask your doctor to:

• Call the insurer’s medical review team directly
• Submit a peer-to-peer review request
• Provide additional clinical justification

Keck Medicine’s 2024 analysis found that when doctors personally engage, appeal success rates jump by 32%. That’s not a small number. It’s the difference between waiting weeks and getting your medication in days. If your doctor’s office says they’re too busy, push back. This is your health. They’re paid to help you get the care you need. If they won’t help, ask for a referral to another provider who will.

Track Everything and Follow Up

After you submit, don’t disappear. Insurers have 30 days to respond, but many take longer. Call every 5-7 days. Ask for the name of the person handling your case. Write it down. If you get another denial, don’t give up. You can appeal again-this time with more evidence. Forty-four percent of appeals require resubmission because of missing info or processing errors. You’re not alone. Keep a log: date submitted, who you spoke with, what they said, what’s next. This helps you stay organized and gives you leverage if you need to escalate.

What If You Still Get Denied?

If your internal appeal is denied, you have the right to an external review. This means an independent third party-not your insurer-looks at your case. You have 365 days from the final denial to request this, but don’t wait. Start the process right away. The No Surprises Act allows for independent dispute resolution in some cases, but it’s rarely used. Only 0.3% of denials go this route. It’s complicated and slow. Focus on getting the internal appeal right first. Also, check if your plan is self-insured. If it is, federal ERISA rules apply. That means they have to respond to your appeal within 60 days. If they don’t, you can file a complaint with the U.S. Department of Labor.

Know Your Numbers

You’re not fighting a faceless system. You’re fighting a flawed process. Here’s what the data shows:

• 6% of prior auth requests are denied-but 82% of appeals get approved
• 41% of denials are due to simple administrative errors
• 92% of doctors spend 1-2 hours per week just handling prior auth issues
• 79% of physicians say patients quit treatment because of delays

That last one is the most important. People die because they can’t get their meds. You’re not just asking for a pill. You’re asking for your health. And you have the right to fight for it.

What to Do Next

1. Get your denial letter. 2. Call your doctor’s office and ask them to help you gather records. 3. Write your appeal letter using the exact reason from the denial. 4. Submit it the way your insurer requires. 5. Call every week until you get a response. It’s not easy. It takes time. But it’s worth it. Thousands of people get their medications approved every month because they didn’t accept the first no. Don’t let bureaucracy steal your treatment. You know your body. Your doctor knows your needs. Now you know how to fight for both.