When North Carolina resident Sally Nix learned her health insurance company had refused to cover an expensive, doctor-recommended treatment for her neurological pain, she braced for a long fight.
It took years of appeals, conflicting insurer decisions, and eventually switching to a new health plan before she finally won approval. She began treatment in January and now devotes her time to helping others facing the same roadblocks.
“One of the things I tell people is: ‘Don’t panic. This isn’t a final no,’” said Nix, 55, of Statesville.
Prior authorization — a cost-control process that requires insurer approval before patients can access certain tests, prescriptions, or procedures — is used by nearly every health plan. But denials are common, and navigating the appeals system can be daunting.
According to a KFF Health News poll released in July, nearly half of insured adults who had a prior authorization denied in the past two years found the appeals process somewhat or very difficult.
“It’s overwhelming by design,” Nix said, arguing that insurers rely on confusion and fatigue to discourage patients from pursuing appeals. “That’s exactly what they want you to do.”
The good news: patients do not need to be insurance experts to succeed. With persistence and strategy, they can overturn denials.
Here are seven steps experts recommend when your prior authorization is denied:
1. Understand Your Insurance Plan
Coverage rules vary depending on whether your plan is employer-sponsored, purchased through Healthcare.gov, Medicare, Medicare Advantage, or Medicaid. Each type is regulated differently, with separate federal and state oversight.
Read your policy carefully. Insurers do not apply prior authorization rules uniformly, and knowing the specifics of your plan is critical to ensuring your insurer follows both its own rules and government regulations.
2. Work With Your Provider to Appeal
Before contacting your insurer, ask your doctor’s office if they are already working on an appeal. Providers often have staff dedicated to handling prior authorization denials and can request a “peer-to-peer” review, where your doctor discusses your case directly with an insurer’s medical reviewer.
“They know the language,” Nix said. “They can be your voice.”
3. Stay Organized
Keep a detailed record of every call, letter, and email. Digital tools like MyChart can help, but a paper trail may be equally important.
“Every call, every letter, every name,” Nix emphasized. “That paper trail saved me.”
Linda Jorgensen of the Special Needs Resource Project recommends requesting a “ticket number” and the name of any insurance representative during phone conversations. She also provides a free printable form to guide note-taking.
“If it isn’t on paper, it didn’t happen,” Jorgensen said.
4. File Appeals Quickly
Time limits matter. Under the Affordable Care Act, patients generally have six months to appeal a denial. Some states and insurers allow less time.
Delays can jeopardize your case, especially if you are mailing documents. Jorgensen advises filing at least a month before the deadline.
Data shows appeals are often successful. KFF analysis of Medicare Advantage plans found that 82% of denials between 2019 and 2023 were at least partially overturned.
5. Use Your Employer’s HR Department
For employer-sponsored insurance, especially “self-funded” plans, coverage decisions may ultimately rest with the employer, not the insurer.
If your doctor recommends a treatment your insurer deems “not medically necessary,” it may be worth asking your HR department to intervene. While not guaranteed, employers sometimes agree to cover care directly.
6. Seek Advocacy Support
Free state-run consumer assistance programs can help patients file appeals and hold insurers accountable. National nonprofits, such as the Patient Advocate Foundation, provide resources, appeal letter templates, and in some cases one-on-one support for patients with serious conditions.
7. Speak Out
Patients who go public — on social media or through their lawmakers — sometimes succeed in reversing denials.
State legislators in particular can influence insurance regulations. While contacting elected officials doesn’t guarantee success, it can pressure insurers to reconsider.
Bottom line: Insurers count on patients giving up, but persistence can pay off. As Nix put it: “You just need to know how to push back.”
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