How to Appeal a Prior Authorization Denial for Your Medication

When your insurance denies coverage for a medication your doctor prescribed, it’s not just a bureaucratic hiccup - it’s a roadblock to your health. You’ve got a prescription, your doctor says it’s necessary, and yet your insurer says no. That denial letter can feel like a punch in the gut, especially if you’re already dealing with a serious condition. But here’s the truth: prior authorization denials are often wrong, and most of them can be overturned. In fact, 82% of appeals get approved when done right. You don’t need a lawyer or a medical degree. You just need to know the steps - and do them carefully.

Understand Why Your Medication Was Denied

The first thing you need to do is read the denial letter. Not skim it. Read it line by line. Insurance companies don’t deny coverage randomly. They give a reason, and it usually falls into one of three categories:

• Incomplete paperwork (37% of denials): Missing forms, wrong patient ID, or unclear doctor notes.
• Lack of medical necessity (48%): The insurer thinks another drug should be tried first, even if your doctor says it won’t work for you.
• Not covered by your plan (15%): The medication isn’t on their approved list, or it’s classified as experimental or non-formulary.

If the letter is vague - saying something like “coverage criteria not met” without specifics - that’s a red flag. You’re entitled to a clear explanation. Call your insurer and ask them to resend the denial with full details. If they refuse, request a formal copy in writing. You’ll need this for your appeal.

Gather Every Piece of Medical Evidence

An appeal isn’t a plea. It’s a case built on facts. The more solid your evidence, the higher your chance of winning. Here’s what you need:

• Your doctor’s written statement explaining why this specific medication is necessary - not just a note, but a full letter.
• Lab results, test reports, or imaging that support your diagnosis.
• History of other medications you’ve tried and why they failed. Be specific: “Metformin at 1000mg daily for 6 months caused severe nausea and no blood sugar improvement.”
• Any side effects you experienced with alternatives.
• Current symptoms and how they’re affecting your daily life.

If your doctor’s office is slow to respond, call them directly. Ask for the medical records department and say you need documentation for an insurance appeal. Most offices have templates they use for this. If they don’t, give them this simple structure: “Patient has [condition]. Prior treatments [list] failed due to [reason]. This medication is clinically indicated per [guideline]. Denial will cause [health risk].”

Follow Your Insurer’s Exact Appeal Process

Every insurance company has its own rules. You can’t just send a letter and hope for the best. You need to follow their procedure to the letter.

• Check your plan documents or their website for the “Appeals and Grievances” section.
• Find out if they require online submission, fax, or mail. CVS/Caremark requires faxing to 1-888-836-0730. UnitedHealthcare requires online portal submission. Get it wrong, and your appeal gets tossed.
• Include your full name, member ID, date of birth, drug name, and the denial date.
• Submit your appeal within 180 days of the denial date. That’s the federal deadline under the Affordable Care Act.

Pro tip: Send everything by certified mail with return receipt. Keep a copy of every document. If you submit online, screenshot the confirmation page. Paper trails save lives.

Write a Clear, Focused Appeal Letter

Your appeal letter isn’t a story. It’s a legal argument. Stick to facts. Use the insurer’s own coverage rules against them.

Start with:

• Your full name and ID number.
• The date of the denial and the drug name.
• A direct reference to the reason given in the denial letter.

Then, respond point by point:

“Your letter dated [date] denied coverage for [drug] because ‘alternative therapies should be tried first.’ However, I have already tried [Drug A] for 4 months and [Drug B] for 3 months, both of which caused [side effect]. My doctor’s records show these treatments were ineffective and unsafe for me. According to your plan’s Clinical Guidelines, Section 4.2, this medication is approved when prior therapies have failed with documented intolerance. I’ve attached all supporting records.”

Include specific codes if possible: ICD-10 diagnosis codes and CPT procedure codes. Studies show 89% of approved appeals include these. If you don’t know them, ask your doctor’s office to add them.

Get Your Doctor Involved

Your doctor’s voice carries weight. Most insurers have a “peer-to-peer review” option - that means a doctor from your plan will talk to your doctor. This step alone increases approval rates by 32%.

Call your doctor’s office and say: “I’m appealing my medication denial. Can you please call the insurer’s medical director to discuss why this drug is medically necessary for me?” Most offices will do this at no cost. If they hesitate, remind them that the AMA says 79% of patients abandon treatment due to prior auth delays - and that’s a risk they’re ethically obligated to prevent.

Track Everything and Follow Up

After you submit your appeal, the insurer has up to 60 days to respond if you’re on a self-insured plan (most employer plans), or 30 days for most commercial plans. But don’t wait. Call every 5-7 business days. Ask for the case number, the name of the reviewer, and a status update.

Keep a log:

• Date of submission
• Method of submission (mail, fax, online)
• Confirmation number
• Names of reps you spoke with
• What they promised

78% of physicians say appeals require multiple follow-ups. Don’t give up. One Reddit user reversed a Humira denial in 7 days by sending a 2-page timeline of failed treatments. Another lost their appeal because they didn’t include the CPT code referenced in the denial letter. Details matter.

What If Your Appeal Gets Denied Again?

If your first appeal is denied, you still have options. You can request an external review - an independent third party that looks at your case. Federal law gives you 365 days from the final denial to do this. Some states have shorter windows (60-180 days), so check your state’s insurance department website.

You can also file a complaint with your state’s Department of Insurance. In 2023, 41% of initial denials were due to simple administrative errors - typos, missing pages, wrong forms. These are fixable. If your insurer is being unreasonable, regulators will take notice.

Know Your Numbers

This isn’t just about one drug. It’s about a broken system. Here’s what you’re up against - and why you need to fight:

• 6% of prior auth requests are denied - that’s about 18.7 million cases a year in the U.S.
• Only 11% of people appeal - but 82% of those appeals succeed.
• 93% of doctors say prior auth causes treatment delays.
• 34% of physicians report patients had adverse health events because they couldn’t get their meds on time.

You’re not alone. And you’re not asking for luxury. You’re asking for the treatment your doctor prescribed - the one that could keep you out of the hospital, off disability, or alive.

What to Do Next

1. Get your denial letter in writing. If you don’t have it, call your insurer and demand it.

2. Ask your doctor for a detailed letter and medical records.

3. Find your insurer’s appeal instructions - don’t guess.

4. Write your appeal letter using the exact reason from the denial.

5. Submit it with all documents and proof of delivery.

6. Call every week until you get a decision.

It takes 6-8 hours of your time. But if you succeed, you could save hundreds or thousands of dollars - and more importantly, you’ll get the medicine you need to stay healthy.