Your doctor says you need an MRI for concerning symptoms, but your insurance company’s computer algorithm says no. The denial letter arrives with medical jargon that makes your head spin, and suddenly you’re wondering if you should just pay out of pocket or skip the test altogether.

Here’s what your insurance company doesn’t want you to know: 82% of prior authorization denials that get appealed are either partially or fully overturned. Yet only about 11% of people actually appeal their denials. That means millions of patients are accepting “no” as a final answer when they could be getting the care they need.

The Numbers Tell the Real Story

Recent data reveals a stunning disconnect in the prior authorization system. In 2023, Medicare Advantage insurers alone processed nearly 50 million prior authorization requests, denying 3.2 million (6.4%). But when patients and doctors challenged those denials, 81.7% of appeals were partially or fully overturned.

This isn’t coincidence. Many denials aren’t based on medical necessity but on processing errors, incomplete paperwork, or insurance companies betting that most people won’t fight back. The system counts on your exhaustion to save them money.

Understanding Why You Got Denied

Before you can fight effectively, you need to understand what went wrong. Common denial reasons include:

Administrative Errors

• Incorrect diagnosis or procedure codes
• Missing documentation from your doctor
• Wrong insurance ID numbers or patient information
• Requests submitted to the wrong department

Medical Necessity Questions

• Insurance reviewer believes a less expensive treatment should be tried first
• Procedure or medication isn’t on their approved list
• Your condition doesn’t meet their specific criteria
• Treatment is labeled “experimental” despite clinical acceptance

Policy Issues

• Service requires a specialist referral you don’t have
• Provider is considered out-of-network
• Annual or lifetime benefit limits reached
• Plan excludes certain treatments or conditions

Your Step-by-Step Appeal Strategy

Step 1: Get the Details

Call your insurance company immediately and ask for the specific reason your request was denied. Request a written denial letter that includes the denial code, reasoning, and instructions for appeal. You typically have 60-180 days to appeal, depending on your insurer.

Step 2: Rally Your Medical Team

Contact your doctor’s office right away. They’re your strongest allies and often have staff dedicated to handling appeals. Ask them to: • Review the denial reason and gather supporting documentation
• Request a peer-to-peer review with the insurance company’s medical director
• Write a detailed letter explaining why the treatment is medically necessary
• Provide clinical studies or guidelines supporting your care

Step 3: Document Everything

Keep detailed records of every phone call, email, and letter. Note the date, time, person you spoke with, and what was discussed. This paper trail becomes crucial if you need to escalate your appeal.

Step 4: Write Your Appeal Letter

Your appeal should be clear and compelling. Include: • Your insurance ID number and the denial reference number
• A clear statement that you’re appealing the denial
• Medical justification for why you need this treatment
• How the denial affects your health and quality of life
• Copies of relevant medical records, test results, and doctor’s notes

Getting Professional Help That Works

You don’t have to navigate this alone. Several organizations specialize in helping patients fight insurance denials:

Patient Advocate Foundation

Patient Advocate Foundation offers free case management services to help resolve insurance denials and prior authorization issues. Their professional case managers work directly with insurers on your behalf and have extensive experience overturning denials. Call 1-800-532-5274.

State Insurance Departments

Your state insurance department can often pressure insurers to reconsider denials, especially if the insurer isn’t following proper procedures. Many states have consumer assistance programs specifically designed to help with health insurance disputes.

Healthcare Attorneys

For complex or high-cost treatments, consider consulting with an attorney who specializes in health insurance law. Many work on contingency, meaning you don’t pay unless you win your case.

Special Weapons in Your Arsenal

Expedited Appeals

If waiting for a standard appeals decision could harm your health, request an expedited review. These must be decided within 72 hours and are harder for insurers to deny when medical urgency is documented.

External Reviews

If your internal appeal fails, most states allow you to request an independent external review by medical experts not employed by your insurance company. These reviewers often overturn insurer decisions at even higher rates than internal appeals.

State and Federal Protections

Several states have passed laws limiting how insurers can use prior authorization. Some require that denials be reviewed by doctors in the same specialty as your condition, while others set strict time limits for approval decisions.

When Appeals Succeed

Most successful appeals result in full approval of the requested treatment or medication. Once you win an appeal, your insurance company cannot drop your coverage, raise your premiums, or retaliate against you in future coverage decisions.

Strong Indicators Your Appeal Will Succeed

Some denials are particularly likely to be overturned:

• Denials based on “experimental” treatments that are widely accepted in medical practice
• Rejections where your doctor is board-certified in the relevant specialty
• Cases where you’ve already tried and failed less expensive treatments
• Denials that contradict published medical guidelines or your plan’s own policies

The Bigger Picture

The high success rate of appeals exposes a fundamental flaw in the current system. Insurance companies often deny legitimate claims knowing that most people won’t fight back, essentially using the complexity of the appeals process as a cost-control measure.

Recent legislative efforts aim to reform this broken system. The AMA and other medical organizations are pushing for “gold card” programs that would exempt doctors with good track records from repetitive prior authorization requirements, and laws requiring insurers to honor existing approvals when patients switch plans.

The Bottom Line

Your insurance company’s first “no” is rarely their final answer. With 81.7% of appeals succeeding, fighting your denial isn’t just worth it—it’s almost irresponsible not to try. The system counts on your acceptance of their initial decision, but you have more power than you realize.

Don’t let administrative hurdles keep you from the care your doctor says you need. Whether it’s that MRI, a newer medication, or a specialized treatment, the odds are strongly in your favor if you’re willing to advocate for yourself. Your health is worth the fight.