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 wondering if you should just give up. But here’s the truth: 82% of prior authorization denials are reversed when you appeal. That’s not luck. That’s a system that’s broken at first glance but fixable if you know how to push back.

Understand Why You Were Denied

The first thing you need to do is read your denial letter. Not skim it. Read it line by line. Most denials fall into three buckets:

• Incomplete paperwork (37% of cases): Missing signatures, wrong IDs, or forms not filled out fully.
• Lack of medical necessity (48%): The insurer says your condition doesn’t meet their criteria for this drug.
• Not covered by plan (15%): The drug isn’t on your plan’s formulary at all, or they want you to try something cheaper first.

You can’t appeal effectively if you don’t know why you were denied. If the letter is vague-something like “coverage criteria not met”-call your insurer’s member services. Ask them to explain exactly what’s missing. Get it in writing. If they won’t give you details, ask to speak to a clinical reviewer. Most people skip this step and lose before they even start.

Gather Every Piece of Medical Evidence

Your appeal isn’t a complaint. It’s a case built on facts. You need to prove your medication is medically necessary. That means collecting:

• Your full medical records from the past 12 months
• Lab results, imaging reports, and specialist notes
• A letter from your doctor explaining why this drug is the only option that works for you
• Proof of failed alternatives: If you tried two other drugs and they didn’t work, list them with dates and side effects

The Obesity Action Coalition found that 63% of successful appeals include detailed records of prior treatment failures. For example, if you’re trying to get Humira approved, don’t just say “other drugs didn’t work.” Say: “On January 12, 2024, I tried Enbrel at 50mg weekly for 12 weeks. I developed severe rash and joint pain worsened by 40%. On March 3, 2024, I tried Cimzia for 8 weeks with no improvement in CRP levels.” Specifics matter. Vague statements get ignored.

Follow Your Insurer’s Exact Process

Every insurance company has its own rules. CVS/Caremark requires appeals to be faxed to 1-888-836-0730 with your full name, ID number, date of birth, and drug name. UnitedHealthcare demands you submit through their online portal. Some require forms you can download from their website. Others accept letters on doctor’s letterhead.

Don’t guess. Go to your insurer’s website. Search for “prior authorization appeal process.” Look for the member handbook or provider portal. If you can’t find it, call their member services and ask for the written appeal guidelines. Keep a copy. If you submit the wrong way-say, email instead of fax-they’ll reject it without reviewing the content.

Write a Clear, Clinical Appeal Letter

Your appeal letter isn’t a plea. It’s a medical argument. Here’s what it must include:

• Your full name, member ID, date of birth
• The name of the medication and the prescribing doctor
• The exact reason for denial (copy it from the letter)
• A point-by-point rebuttal using clinical evidence
• References to the insurer’s own coverage policy
• Doctor’s signature and contact info

Dr. Sonali Patel at Keck Medicine says the key to a 85%+ success rate is aligning your letter with the insurer’s own rules. If their policy says “drug must be tried after two failures,” then list those two failures. If their policy says “only if HbA1c > 9.0,” then show your last lab result. Don’t argue about cost. Don’t say “I can’t afford it.” Say “This is the only drug that has controlled my condition after X, Y, Z failed.”

Get Your Doctor Involved

This is the single biggest factor in winning an appeal. A letter from your doctor carries far more weight than a patient’s letter. But not all doctor letters are equal.

A weak letter says: “Patient needs this drug.”

A strong letter says: “Patient has rheumatoid arthritis with inadequate response to methotrexate and adalimumab. CRP elevated at 18 mg/L. Pain score 8/10. Previous trials of etanercept and certolizumab resulted in loss of efficacy and skin reactions. Humira is the only remaining FDA-approved biologic with documented efficacy in this patient profile per ACR guidelines. Denial delays care and risks joint damage.”

Keck Medicine’s 2024 analysis found that appeals with direct physician input have a 32% higher success rate. If your doctor refuses to help, ask for a referral to a specialist who will. Sometimes, a rheumatologist or endocrinologist writing on your behalf makes all the difference.

Track Everything and Follow Up

Once you submit your appeal, mark your calendar. Insurers have 30 days to respond under federal guidelines-but many take longer. Some don’t respond at all.

Keep a log:

• Date you submitted
• Method (fax, portal, mail)
• Confirmation number
• Name of person you spoke to
• Next follow-up date

Call after 10 business days if you haven’t heard back. Ask for the status. Ask who’s reviewing your case. If they say “it’s in queue,” ask for the name of the clinical reviewer. Most people give up after one call. But 44% of appeals require resubmission due to processing errors. You have to stay on top of it.

Know Your Next Steps if You’re Still Denied

If your appeal is denied, you’re not out of options. You have two paths:

1. External Review: You can request an independent third party to review your case. By law, you have 365 days from your final denial to do this. The review is free and binding on the insurer. Healthcare.gov confirms this option is available to all commercial plans.
2. State Insurance Commissioner: If your plan is state-regulated (not self-insured), you can file a complaint with your state’s insurance department. In Massachusetts, this process takes 45 days and often forces a reversal.

For self-insured plans (common with large employers), you’re covered under ERISA. Under ERISA, the plan must respond to your appeal within 60 days. If they don’t, you can file a federal complaint.

What to Do If You Can’t Wait

If you’re running out of medication and can’t wait 30-60 days for an appeal, ask your doctor for a 30-day emergency supply. Many insurers allow this if your doctor certifies you’ll be harmed without it. You can also ask your pharmacy if they offer a patient assistance program. Many drugmakers-like AbbVie for Humira or Novo Nordisk for Ozempic-have free or low-cost programs for people who can’t afford their meds.

Why So Few People Appeal (And Why You Should)

Only 11% of people appeal a denial-even though 82% win. Why? Because it’s time-consuming. Physicians spend 1-2 days a week just handling prior auths. Patients don’t know where to start. The system is designed to make you give up.

But here’s what no one tells you: 41% of initial denials are due to simple administrative errors. A wrong ID number. A missing signature. A form not stamped. These aren’t medical decisions-they’re clerical mistakes. You can fix them.

And if you do appeal? You’re not just getting your medication. You’re pushing back on a broken system. The more people appeal, the more insurers have to fix their processes. In 2024, Medicare Advantage plans had to cut prior auth response times from 14 days to 72 hours. That happened because patients and doctors pushed back.

Common Mistakes That Kill Your Appeal

• Waiting too long to start. You have 180 days to appeal. Don’t wait until day 179.
• Not including CPT or ICD-10 codes. 89% of approved appeals include these. Your doctor’s office can give them to you.
• Using emotional language. “I need this to live” won’t help. “I have uncontrolled Type 2 diabetes with HbA1c of 10.2% despite metformin and GLP-1 agonists” will.
• Not following the insurer’s format. Submitting a letter when they require a form = automatic denial.
• Not keeping copies. Always send documents via certified mail or get a submission receipt.

Real Success Story

A patient in Boston, diagnosed with Crohn’s disease, was denied Stelara after two failed biologics. Their first appeal was rejected because they didn’t include the CPT code for the infusion procedure referenced in the denial. They resubmitted with:

• A 2-page timeline of failed treatments with dates and lab values
• The exact ICD-10 code for Crohn’s (K50.00)
• A letter from their gastroenterologist citing ACG guidelines
• Proof of prior authorization for the two failed drugs

They got approved in 7 business days.

Final Thought

This isn’t about being stubborn. It’s about being informed. You’re not fighting your insurance company-you’re using the rules they agreed to follow. The system is flawed, but it’s not invincible. You have rights. You have evidence. And you have a better than 8 in 10 chance of winning if you do it right.