Prior Authorization Denial Appeal Letter

Don't treat a denial as final. KFF, the health policy research group, found that only 11.5% of the 4.1 million prior authorization denials Medicare Advantage insurers issued in 2024 were appealed. Yet in every year from 2019 to 2024, more than 8 in 10 appealed denials were overturned¹, fully or in part.

Before you draft, copy these from the notice:

• The stated reason, word for word
• Any policy, guideline or criterion it cites
• Anything it says is missing
• The service, codes, case number and notice date
• Who may appeal, the deadline and where to file

An employer plan's notice has to describe any additional information needed to complete the claim, and explain why². It must also share the guideline it relied on, or offer a free copy. That description is often your to-do list.

The clock starts with the notice. Medicare Advantage allows 65 calendar days from the notice date³, Medicaid managed care 60 days from the notice date⁴, and employer plans at least 180 days from receipt². Marketplace plans must follow the employer-plan rules⁵, so they also allow at least 180 days.

In Medicare Advantage, the patient's physician can request the reconsideration³. Medicaid plans accept a provider's appeal with the patient's written consent, where state law allows⁴. Employer and marketplace plans can ask for a form naming a representative, but for urgent care they must let a clinician who knows the patient's condition act for them².

Answer each stated reason with a fact from the chart: what was found, when, by whom, and the enclosure that shows it. If the plan cited several reasons or criteria, answer each one in its order.

Write for a reviewer who wasn't part of the first decision. In Medicare Advantage, a medical necessity denial must be reconsidered by a physician with expertise in the field, not necessarily in your specialty⁷. So spell out scores and abbreviations, give units, and say why each finding meets the criterion.

Send what the first request lacked. An employer plan's review must weigh everything you submit, whether or not it was part of the original claim². If something changed since the request, such as a new symptom, say so and enclose the note.

Keep it to a page or two, in this order:

1. 1

   Identify the case

   Date, the plan's appeals address, and a reference line with the patient, member ID, case number, service and codes.

2. 2

   Say who is appealing

   The treating clinician, appealing for the patient, and the decision under appeal, with its notice date.

3. 3

   Quote the reason

   The plan's stated reason, word for word, before any argument of your own.

4. 4

   Answer each point

   One numbered response per reason or criterion, each with its dated evidence and enclosure number.

5. 5

   List prior treatments

   For step therapy, a table of each drug or therapy: dose, dates, result and why it stopped.

6. 6

   Ask, sign and enclose

   One sentence on what to approve, a direct line for a peer-to-peer call, the clinician's signature and the enclosure list.

Each plan type has an expedited appeal for cases where the standard wait could seriously jeopardize the patient's life, health or ability to regain maximum function. The plan then has 72 hours to decide. In Medicare Advantage, if a physician asks for an expedited appeal, the plan must expedite it³.

Employer and marketplace plans must treat an appeal as urgent when a physician who knows the patient's condition says it is². In an urgent case you can also request an expedited external review at the same time as the internal appeal⁵.

Ask for expedited review only when the clinician judges the risk real, and put the dated findings behind that judgment in the letter.

Send it by the route the notice names, and keep proof of the date it arrived. Note when the decision is due, and log every call: the date, who you spoke to and what was said.

When the plan offers a peer-to-peer call with its reviewing physician, the clinician should take it with the denial and key notes at hand. Keep the written appeal moving, since the filing deadline keeps running.

If the denial stands, go to the next level. A Medicare Advantage plan must send an upheld denial to an independent review entity³ without being asked. Most employer and marketplace plans offer external review by an independent organization, requested within 4 months⁵. Medicaid enrollees can ask for a state fair hearing⁴.

For the next request, a medical necessity letter answers the plan's criteria one by one, and a prior authorization request template tracks what each payer asks for. For claims denied after care, use the insurance denial appeal letter template. To draft this appeal, paste the denial and the clinician's notes into the tool at the top of this page.