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’re not alone. About 6% of prior authorization requests get denied upfront, and for many, that’s the end of the story. But here’s the truth: 82% of those denials get reversed when you appeal. That’s not luck. That’s a system you can beat-if you know how.

Understand Why Your Medication Was Denied

The first thing you need to do is read your denial letter. Not skim it. Read it. Insurance companies don’t deny medications randomly. They have specific reasons, and they’re usually one of three things:

• Incomplete paperwork (37% of cases)-missing forms, wrong ID numbers, or unsigned documents.
• Lack of medical necessity (48% of cases)-they think another drug should work first, even if your doctor says it won’t.
• Not covered by your plan (15% of cases)-the drug is excluded, or you didn’t try cheaper alternatives first.

If your denial letter says something vague like “not medically necessary” without explaining why, that’s a red flag. You’re entitled to a clear reason. Call your insurer and ask them to send you a detailed explanation. Keep a copy of everything-emails, letters, notes from phone calls.

Gather the Right Documentation

You can’t appeal with just a letter from your doctor. You need evidence. Here’s what works:

• Your full name, member ID, and date of birth-exactly as they appear on your insurance card.
• The exact name of the medication, including dosage and quantity.
• Medical records showing your diagnosis (ICD-10 code), treatment history, and why this drug is needed.
• Lab results, test reports, or specialist notes proving other treatments failed.
• A letter from your doctor that answers the insurer’s specific denial reason.

One patient successfully appealed a Humira denial after including a two-page timeline showing exactly which drugs they tried, when, and what side effects they had. Another appeal failed because they didn’t include the CPT code mentioned in the denial. Details matter. If your insurer says “submit clinical documentation,” don’t send your whole chart. Send only what’s relevant-highlighted, labeled, and organized.

Know Your Insurer’s Rules

Every insurance company has its own process. CVS/Caremark requires appeals to be faxed to a specific number. UnitedHealthcare insists you use their online portal. If you submit the wrong way, your appeal gets thrown out-even if everything else is perfect.

Check your member handbook or call the number on your insurance card and ask: “What’s your formal appeal process for prior authorization denials?” Write down the steps. Some require:

• A signed appeal form
• A specific cover letter template
• Submission within 180 days

For self-insured plans (common with big employers), federal law under ERISA requires them to respond within 60 days. If they don’t, you can move to the next step. Don’t wait. Track your submission date and keep proof you sent it-certified mail, email receipt, portal confirmation.

Write a Strong Appeal Letter

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

1. State your request clearly: “I am appealing the denial of [medication name] for [diagnosis].”
2. Address the denial reason directly: If they said “failed step therapy,” list every drug you tried, when, and why it didn’t work.
3. Use their own guidelines: Most insurers publish coverage policies online. Quote the exact criteria your doctor met. For example: “Per your 2025 Specialty Drug Policy, Section 4.2, this medication is indicated for patients with [condition] after failure of [drug class].”
4. Include your doctor’s clinical rationale: “Dr. Patel confirms that [medication] is the only option that addresses my [symptom] without triggering [side effect].”
5. End with urgency: “Delaying this treatment risks [specific health consequence].”

Doctors who write these letters themselves-instead of just signing a form-see their appeals approved 32% more often. Don’t just ask your doctor to sign. Ask them to write a short, specific letter that matches the insurer’s language.

Get Your Doctor Involved

This is where most people fail. You can’t just send a letter and hope. Your doctor needs to talk to the insurance company.

Call your doctor’s office and say: “My medication was denied. Can you call the insurer’s medical review team directly?” Most offices have a provider relations line. Ask them to request a peer-to-peer review-where your doctor speaks to a doctor employed by the insurer. This step alone increases approval odds dramatically.

If your doctor refuses or says it’s “not their job,” ask for a referral to a patient advocate. Many hospitals and nonprofits offer free advocacy services. The Obesity Action Coalition and the American Medical Association both have resources to help you find one.

Track Everything and Follow Up

Insurance companies have 30 days to respond-but many take longer. Don’t wait. After 10 business days, call and ask for the status. Ask for the name of the person handling your case. Write it down.

Keep a log:

• Date you submitted appeal
• Method of submission (fax, portal, mail)
• Confirmation number or receipt
• Names and titles of people you spoke to
• What they said

Forty-four percent of appeals get denied because of a clerical error-wrong ID, missing page, wrong form. Your log helps you catch these fast. If you get another denial, don’t give up. You have the right to appeal again.

Request an External Review

If your internal appeal is denied, you can ask for an external review by an independent third party. This is your final step.

You have 365 days from the final denial to request this, but don’t wait. The process can take 30-60 days. Some states have shorter windows-check your state’s insurance department website.

The external reviewer doesn’t work for your insurer. They look at your case like a judge. They’ll review your records, your doctor’s notes, and the insurer’s reasons. Over 70% of external reviews favor the patient when the appeal was well-documented.

What to Do If You’re Still Denied

If every step fails, you still have options:

• Ask for a hardship exception: If the drug is life-saving or you can’t afford it, some insurers will approve it under financial hardship.
• Use patient assistance programs: Most drug manufacturers offer free or discounted medication for qualifying patients. Go to NeedyMeds.org or the manufacturer’s website.
• Switch plans: If you’re on Medicare Advantage, you can change plans during open enrollment. Some plans have lower prior authorization rates.
• File a complaint: Contact your state’s insurance commissioner. In 2023, over 12,000 complaints about prior authorization denials were filed nationwide. Many led to policy changes.

Why This System Is Broken-and How to Beat It

The average physician spends 1-2 hours a week just managing prior authorizations. That’s time taken from patients. Nearly 80% of doctors say patients have quit treatments because of delays. One in four patients abandon prescriptions after a denial.

This isn’t about insurance companies being evil. It’s about a broken system designed to delay, not protect. But you’re not powerless. The data shows: if you appeal, you win most of the time.

The real secret? Don’t treat this like a form to fill out. Treat it like a medical case you’re presenting to a judge. Be precise. Be persistent. Use facts. And don’t let them bury your request in paperwork.