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 a paperwork headache-it’s a health risk. In 2024, prior authorization denials blocked over 18 million prescriptions in the U.S., and nearly 9 out of 10 doctors say patients delay or quit treatment because of them. But here’s the truth most people don’t know: if you appeal, you have an 82% chance of winning. That’s not luck. It’s a system that’s broken at the start-and fixable if you know how to fight back.

Understand Why It Was Denied

The denial letter you get isn’t just a form letter. It’s your roadmap. Most denials fall into three buckets: missing paperwork (37%), the insurer doesn’t believe the drug is medically necessary (48%), or it’s simply not covered under your plan (15%). You can’t appeal effectively unless you know which one applies to you.

Look for specific phrases like “lack of medical necessity,” “alternative therapy preferred,” or “not on formulary.” If it says “insufficient documentation,” that’s your cue to gather more. If it says “step therapy required,” that means you tried other drugs first-and you need to prove you did.

Don’t ignore this step. A 2024 analysis from Keck Medicine found that appeals failing to match the denial reason exactly had a 60% lower success rate. You’re not arguing general fairness-you’re proving the insurer made a mistake based on their own rules.

Gather Every Piece of Medical Evidence

Your doctor’s note alone won’t cut it. Insurers need proof that your treatment is necessary, not just reasonable. You need:

• Full medical records from the past 6-12 months
• Lab results showing why other drugs failed
• Specific dates and outcomes of prior treatments
• Physician statement explaining why this drug is the only option
• Any hospitalization or ER visits tied to untreated symptoms

The Obesity Action Coalition found that 63% of successful appeals included a clear timeline of failed alternatives. For example: “Patient tried Metformin 1000mg daily for 6 months (HbA1c dropped from 9.1 to 7.8). Added GLP-1 agonist for 4 months (HbA1c 7.5, severe nausea). Patient cannot tolerate other options. This medication is medically necessary.”

Don’t forget the codes. CPT and ICD-10 codes matter. If the denial mentions “CPT 99213,” make sure your records reference it. A 2023 AMA study showed 89% of approved appeals included correct diagnostic and procedure codes. If your doctor doesn’t know these codes, ask them to pull the claim form-they’ve seen it before.

Follow Your Insurer’s Exact Process

Every insurer has its own rules. CVS/Caremark requires appeals to be faxed to 1-888-836-0730 with your full name, ID number, drug name, and physician statement. UnitedHealthcare demands online submissions through their provider portal. Humana wants a signed letter on letterhead. Get this wrong, and your appeal gets tossed-no second chances.

Call your insurer’s member services. Ask: “What is the exact process to file a formal appeal for a prior authorization denial?” Write down the name, date, and time of the rep you speak with. If they say “just send a letter,” ask for their written appeal policy. Most insurers have it online under “Member Services” or “Appeals & Grievances.”

You have 180 days from the denial date to file, according to Healthcare.gov. But don’t wait. The average review time is 30 days. If you wait until day 170, you’ll have no room for a second try.

Write a Clear, Specific Appeal Letter

Your letter isn’t a plea. It’s a rebuttal. Start with your personal info: full name, date of birth, member ID, date of denial, drug name, and prescription number. Then get straight to the point:

• “My denial letter dated [date] states [exact reason].”
• “This is incorrect because [evidence].”
• “Per your plan’s formulary guidelines, Section 4.2, this drug is covered when [condition] is met.”
• “Attached are records showing [specific failure of alternatives].”
• “I request immediate approval to avoid worsening of [condition].”

Use plain language. No medical jargon unless it’s from your records. Don’t say “I’m in pain.” Say “Patient reports uncontrolled neuropathic pain (NRS 8/10) despite 3 months of gabapentin, with documented sleep disruption and inability to work.”

Sign it. Date it. Send it certified mail or upload it with a confirmation number. Keep a copy.

Get Your Doctor Involved

This is the single biggest factor in winning. A 2024 Keck Medicine study showed appeals with direct physician communication to the insurer had a 32% higher approval rate. Your doctor doesn’t just write a note-they need to call the insurer’s medical review team.

Ask your doctor’s office to:

• Submit a clinical appeal letter on official letterhead
• Call the insurer’s provider relations line (ask for the number when you call member services)
• Request to speak with a medical director or clinical reviewer

Many offices have a prior auth specialist on staff. If they say they’re too busy, offer to draft the letter for them to sign. Most will do it if you make it easy.

Track Everything and Follow Up

Insurers often say they’ll respond in 30 days. They rarely do. In the AMA’s 2023 survey, 78% of doctors had to call multiple times to get an update.

Create a simple log:

• Date submitted
• Method (fax, online, mail)
• Confirmation number
• Who you spoke with
• Next follow-up date

Call every 5-7 days after submission. Say: “I submitted an appeal on [date] for [drug]. Can you confirm it’s under review? What’s the status?”

If you get a second denial, you can request an external review. You have up to 365 days from the final denial to do this, but state rules vary. Medicare Advantage plans must respond within 72 hours for urgent cases-use that if your condition is worsening.

What If You Still Get Denied?

If your appeal fails, you have options:

• Request an external review through your state’s insurance department
• Ask your doctor about patient assistance programs (PAPs)-many drug makers offer free medication for qualifying patients
• Check if your plan offers a formulary exception process
• Consider switching to a different plan during open enrollment

Some patients get lucky with manufacturer coupons. Others find the same drug at a cash price cheaper than their copay. Always ask your pharmacist: “Is there a lower-cost version or generic alternative?”

Why Most People Fail-And How to Avoid It

The biggest mistake? Thinking the denial is final. It’s not. The system is designed to make you give up. But here’s what the data shows:

• Only 11% of denials are appealed-even though 82% get reversed
• 41% of denials are due to simple clerical errors-easily fixed
• 92% of physicians spend 1-2 hours a week just managing prior auth
• Patients who appeal are 8x more likely to get their medication than those who don’t

You’re not fighting a faceless corporation. You’re fighting a broken process. And the process is full of mistakes.

If you’ve been told “no,” don’t accept it. Get the letter. Gather the records. Call your doctor. Write the letter. Follow up. You’ve already done the hard part-you took your health seriously. Now finish it.

What to Do Next

1. Find your denial letter. If you don’t have it, call your insurer and ask for a copy.

2. Call your doctor’s office. Ask them to help you with the appeal.

3. Write your letter using the template above.

4. Submit it the way your insurer requires.

5. Call every week until you get a yes.

This isn’t a quick fix. But it’s the only way to get the medicine you need. And you’re not alone. Every year, hundreds of thousands of people win these appeals. You can too.