How to Appeal an Insurance Denial

How to Successfully Appeal an Insurance Denial

Successfully appealing an insurance denial requires understanding why your claim was denied, gathering the right evidence, and presenting a compelling case. The good news? Over 50% of appealed insurance denials are eventually overturned when policyholders follow the proper process.

Insurance companies deny claims for many reasons — some legitimate, others not. Common denial reasons include lack of medical necessity, missing prior authorization, incomplete documentation, out-of-network providers, or coding errors. Understanding your specific denial reason is the first step to crafting a winning appeal.

Whether you're dealing with a health insurance denial, a medication denial for drugs like Zepbound or Wegovy, or a car insurance claim dispute, the core appeal process remains similar. The key is acting quickly, documenting everything, and making your case clearly.

Step-by-Step Guide to Appealing an Insurance Denial

Follow these six steps to maximize your chances of a successful appeal. Each step builds on the previous one, creating a strong foundation for your case.

How to Write an Appeal Letter for an Insurance Denial

A well-written appeal letter can make the difference between approval and denial. Your letter should be professional, specific, and backed by evidence. Here's what to include and sample letters you can use as templates.

What to Include in Your Appeal Letter

• Your information: Full name, policy number, claim number, date of service, and contact information
• Clear statement of appeal: "I am writing to formally appeal the denial of claim #[number]"
• Denial reason: Quote the exact reason from your denial letter
• Your argument: Explain specifically why the denial should be overturned
• Supporting evidence: Reference all attached documentation
• Request for action: Clearly ask for the claim to be approved and paid

Sample Appeal Letter for Health Insurance Denial

[Your Name]
[Your Address]
[City, State ZIP]
[Date]

[Insurance Company Name]
Appeals Department
[Insurance Company Address]

Re: Appeal of Claim Denial
Policy Number: [Your Policy Number]
Claim Number: [Your Claim Number]
Date of Service: [Date]

Dear Appeals Review Committee:

I am writing to formally appeal the denial of my claim referenced above. According to your letter dated [date], the claim was denied because [quote exact reason from denial letter].

I respectfully disagree with this decision for the following reasons:

[Explain why the denial is incorrect. Reference specific policy language, medical necessity, or other relevant factors.]

To support this appeal, I have enclosed:
• Letter of medical necessity from [Dr. Name]
• Medical records documenting [relevant condition/treatment]
• [Other supporting documents]

Based on this evidence, I request that you overturn the denial and approve coverage for this claim.

Please contact me at [phone] or [email] if you need additional information.

Sincerely,
[Your Signature]
[Your Printed Name]

Enclosures: [List all attachments]

Sample Appeal Letter for Medication Denial (Zepbound, Wegovy, etc.)

[Your Name]
[Your Address]
[City, State ZIP]
[Date]

[Insurance Company Name]
Pharmacy Appeals Department
[Insurance Company Address]

Re: Appeal of Prescription Denial - [Medication Name]
Policy Number: [Your Policy Number]
Rx Claim Number: [Claim Number]

Dear Appeals Committee:

I am appealing the denial of coverage for [Medication Name, e.g., Zepbound/Wegovy] prescribed by my physician, [Dr. Name], for the treatment of [condition, e.g., obesity/Type 2 diabetes].

Your denial letter states [quote reason, e.g., "not medically necessary" or "step therapy required"]. I believe this denial should be overturned because:

1. Medical Necessity: I have a BMI of [XX] and have been diagnosed with [related conditions such as hypertension, sleep apnea, pre-diabetes]. My physician has determined that [medication] is medically necessary for my treatment.

2. Previous Treatment Attempts: I have previously tried [list other medications or treatments] without adequate results, as documented in the attached medical records.

3. Clinical Guidelines: [Medication] is FDA-approved for [indication] and is recommended by [relevant medical guidelines, e.g., American Association of Clinical Endocrinology].

Enclosed please find:
• Letter of medical necessity from [Dr. Name]
• Medical records showing BMI history and related conditions
• Documentation of previous treatment attempts
• Relevant clinical guidelines

I request that you approve coverage for [medication] as prescribed.

Sincerely,
[Your Signature]
[Your Printed Name]

How to Appeal an Insurance Denial Online

Many insurance companies now offer online appeal submission through their member portals. Online appeals can be faster and easier to track than mail. Here's how to appeal different types of insurance denials online.

Health Insurance Denial Appeals

Health insurance denials are among the most common and most frequently overturned on appeal. Whether your claim was denied for lack of medical necessity, prior authorization issues, or out-of-network care, you have strong rights to appeal. Under the Affordable Care Act, all health insurers must provide at least two levels of internal appeal plus an external review option.

For urgent health situations, you can request an expedited appeal that must be decided within 72 hours. Always ask if an expedited review is available when your health is at immediate risk.

Medication Denial Appeals (Zepbound, Wegovy, and More)

Prescription denials for newer medications like Zepbound, Wegovy, and other GLP-1 drugs for weight loss or diabetes are increasingly common due to high costs. These denials often cite "not medically necessary" or require "step therapy" (trying cheaper drugs first).

To successfully appeal a medication denial, work closely with your prescribing physician to document: your diagnosis, BMI and weight history, previous medications tried and why they failed, any obesity-related health conditions, and why this specific medication is necessary for your treatment. Many medication denials are overturned when proper medical necessity is established.

Car Insurance Denial Appeals

Car insurance claim denials often involve disputes over fault, coverage limits, or policy exclusions. Unlike health insurance, car insurance appeals don't have the same legal protections, but you still have options. Start by requesting a detailed written explanation of the denial, then gather evidence like photos, police reports, witness statements, and repair estimates to support your case.

If your car insurance appeal is denied, you can file a complaint with your state's insurance commissioner or pursue the matter through small claims court or arbitration.

UnitedHealthcare and Blue Cross Blue Shield Appeals

Major insurers like UnitedHealthcare, Blue Cross Blue Shield, Aetna, and Cigna all have established appeal processes. Most offer online submission through their member portals where you can upload documents, track status, and receive decisions electronically.

When appealing to these large insurers, be thorough and professional. Reference your policy's specific language, include all supporting documentation, and follow up regularly. These companies process thousands of appeals, so making yours clear and complete helps it get the attention it deserves.

Specialized Appeal Guides by Insurance Type

Different types of insurance denials require different appeal strategies. Choose the guide that matches your situation for detailed statistics, sample letters, and step-by-step instructions.

What Happens If Your Insurance Appeal Is Denied?

If your first appeal is denied, don't give up — you still have options. Understanding the difference between internal appeals and external reviews is key to knowing your next steps. According to the Kaiser Family Foundation (KFF), fewer than 1% of consumers appeal their denied claims — yet those who do often succeed.

Internal Appeals vs. External Review

Internal appeals are reviewed by your insurance company. According to HealthCare.gov, most plans require internal appeals within 180 days (about 6 months) from the denial notice. During an internal appeal, a different reviewer (who wasn't involved in the original denial) examines your case.

External reviews are conducted by an independent third party — not your insurance company. Under the Affordable Care Act, you have the right to an external review for most health insurance denials after exhausting internal appeals. External reviewers have no financial relationship with your insurer, making this a powerful option.

According to healthcare industry research, 60-80% of external reviews result in the denial being overturned, especially for medical necessity disputes. If your insurer denies your internal appeal, always request an external review.

State Insurance Commissioner

You can also file a complaint with your state's insurance commissioner or department of insurance. While they can't force an insurer to pay a specific claim, they can investigate unfair practices and often help resolve disputes. Find your state insurance commissioner at NAIC.org.

Appeal Timelines to Know

Claim Denied? What to Do Next

Just received a denial letter? Don't panic — and don't give up. Here's your immediate action plan:

Remember: insurance companies count on people not appealing. By simply filing an appeal with proper documentation, you've already beaten the odds. More than half of appealed claims are eventually approved.

Frequently Asked Questions About Insurance Denial Appeals