• Jul 24, 2025
• By Brian

How to Appeal a Health Insurance Claim Denial Letter

Receiving a health insurance claim denial can be frustrating, especially when you believe the treatment or service should have been covered. However, denials are not always final—many can be successfully appealed. This guide will walk you through the steps to challenge a denial and increase your chances of approval.

1. Understand the Reason for Denial

Insurance companies must provide a clear explanation for claim denials. Common reasons include:

• Lack of medical necessity
• Missing or incorrect information
• Services not covered under your plan
• Pre-authorization requirements not met
• Coding errors (e.g., incorrect ICD-10 or CPT codes)

Carefully review the denial letter to identify the specific issue before proceeding.

2. Gather Supporting Documentation

To strengthen your appeal, collect:

• A copy of the denial letter
• Your insurance policy details
• Medical records and doctor’s notes
• Relevant test results or imaging reports
• Letters of medical necessity from your healthcare provider
• Any prior correspondence with the insurer

3. Follow the Insurer’s Appeal Process

Most insurers have a formal appeals process with strict deadlines (often 30–180 days). Steps may include:

1. Internal Appeal: Submit a written request for reconsideration to the insurer.
2. External Review: If the internal appeal fails, request an independent third-party review (mandatory under the Affordable Care Act for most plans).

4. Write a Strong Appeal Letter

Your appeal letter should be concise, professional, and include:

• Patient and policyholder details (name, ID, claim number)
• A clear statement disputing the denial
• Evidence supporting medical necessity (e.g., peer-reviewed studies, clinical guidelines)
• A request for prompt reevaluation

5. Escalate If Necessary

If appeals are exhausted, consider:

• Filing a complaint with your state’s insurance commissioner
• Seeking legal advice for wrongful denials
• Contacting patient advocacy organizations (e.g., Patient Advocate Foundation)

Final Tips

• Keep copies of all documents and correspondence.
• Meet all deadlines to avoid forfeiting your right to appeal.
• Politely follow up with the insurer if the process is delayed.

By taking these steps, you can systematically challenge a wrongful denial and advocate for the coverage you deserve.