Appeal a denial
Ask your plan to change a “no.” Your deadline, what to send, and a letter.
- Deadline
- File within 180 days of the denial notice.
- Decision time
- The plan must decide within 30 days for care you haven’t received yet, or 60 days for care already received.
Steps
- 01Get the denial in writing and note the date, claim or reference number, and the exact reason and plan rule cited.
- 02Call the plan and ask for a free copy of your claim file and the rules it used to decide (you have a right to them).
- 03Ask your doctor for a letter saying why you need this care (a letter of medical necessity), and copies of your records.
- 04Internal appeal with your plan: File within 180 days of the denial notice. Send it in a trackable way (portal upload with confirmation, fax confirmation, or certified mail) and keep copies of everything.
- 05If the plan still says no, ask for an independent external review (someone outside the plan decides), usually within 4 months. If the reviewer sides with you, the plan must pay.
Evidence to gather
- A letter from your doctor saying why you need this care (a letter of medical necessity)
- Your doctor’s notes, test results, and scan reports
- Medical guidelines or published studies that back the treatment
- The plan’s own clinical policy for the service (request it if you don’t have it)
Appeal letter
7 blanks left to fill: Plan name; Where the notice says to send appeals; Your name; Member ID…
November 14, 2026 [Plan name] — Appeals Department [Address or fax number from your denial notice] Re: Appeal of denial for Occupational therapy Member name: [Your name] Member ID: [From your insurance card] Claim or reference number: [From your denial notice] Date of denial: [Date] To whom it may concern: I am writing to appeal the decision to deny coverage for Occupational therapy, which was denied as not medically necessary. I respectfully request that you reverse this decision. My treating clinician has determined that this care is medically necessary for my condition. The enclosed records document my diagnosis, symptoms, prior treatments that were tried and did not work, and why this service is the appropriate next step under accepted clinical guidelines. Please also send me a copy of all documents, records, and clinical criteria relevant to this decision, and the name and credentials of the reviewer. If this appeal is denied, please explain the specific reason and my rights to further review. Enclosed: - A letter from your doctor saying why you need this care (a letter of medical necessity) - Your doctor’s notes, test results, and scan reports - Medical guidelines or published studies that back the treatment - The plan’s own clinical policy for the service (request it if you don’t have it) Thank you for your prompt attention. Sincerely, [Your name] [Phone number]
Did this help you figure out your next step?
General information, not legal advice. Some plans (certain self-funded, grandfathered, and state programs) have different deadlines. Always follow the deadline printed on your denial notice. Free help is available from your state’s consumer assistance program, or from your State Health Insurance Assistance Program (SHIP) for Medicare.