What to Do When Your Prior Authorization Is Denied

Understanding Prior Authorization

Prior authorization (PA) is a requirement from your insurance company to approve a specific service, procedure, or medication before it is provided. It's a way for insurers to make sure the treatment is medically necessary and cost-effective.

Common Services Requiring Prior Authorization:

• MRIs or CT scans
• Certain prescription drugs, especially specialty medications
• Surgeries or hospital procedures
• Physical therapy
• Durable medical equipment (e.g., wheelchairs, CPAP machines)
• Mental health or behavioral therapy sessions

When a prior authorization is denied, your health plan has determined—often based on paperwork—that the treatment doesn't meet certain criteria. But this isn’t the end of the road.

Reasons Why Prior Authorization Requests Are Denied

Insurance companies may deny prior authorization requests for several reasons:

• Incomplete or missing documentation: Your provider may not have submitted enough medical records or clinical notes.
• Treatment not deemed medically necessary: This often stems from unclear evidence or a mismatch with plan requirements.
• Out-of-network provider: Your insurance might not cover services from providers outside their preferred network.
• Use of non-formulary medication: A prescribed drug may not be on your insurance plan’s approved list.
• Incorrect CPT or diagnosis codes: Administrative errors can trigger a denial even if the treatment is appropriate.

First Steps to Take if Your Prior Authorization Is Denied

Don’t panic. Follow these steps:

Request a Denial Letter: This formal explanation includes the denial code, reasoning, and instructions on how to appeal.

Find Out the Denial Reason: Ask your provider’s office to help interpret the reason. Denials are often caused by clerical rather than clinical issues.

Ask About a Peer-to-Peer Review: This is a conversation between your provider and the insurance company’s medical reviewer to discuss why the treatment is necessary.

Review Your Insurance Plan: Understanding what your plan does and doesn’t cover can help determine whether you have a strong basis for appeal.

How to Appeal a Denied Prior Authorization Request

You typically have 60 to 180 days from the denial to file an appeal, depending on your insurer.

Types of Appeals:

Internal Appeal: Submitted directly to your insurance company. You or your provider writes a detailed appeal letter explaining why the treatment, service, or medication is necessary. This includes cases involving denied prescriptions and follows the standard medication appeal process when drugs are involved.

External Review: If the internal appeal fails, you can request an independent third party to review your case — especially helpful in complex or high-cost treatment scenarios, including prescription drug appeals after prior authorization rejections.

What to Include in a Prior Authorization Appeal Letter

A strong appeal letter includes:

• A clear statement of appeal: For example, “I am writing to appeal the denial of authorization for…”
• Medical justification: How the treatment relates to your condition and why it’s necessary
• Clinical documentation: Test results, chart notes, prior failed treatments, and any guidelines supporting your request
• Provider input: A signed letter from your physician can significantly strengthen the case
• Your insurance ID number and denial reference number

Documentation Required for a Successful Appeal

• Medical records and clinical notes
• Letter of medical necessity from your doctor
• Original denial letter from insurance
• Relevant diagnostic test results
• Treatment history, especially if alternatives failed
• CPT or ICD-10 codes used in the request
• Any correspondence with your insurance company

Timeline for the Appeal Process

How long an appeal takes depends on the type of request and the stage of the process. Here's what to expect:

• Peer-to-peer reviews are usually scheduled within 5 to 10 business days after the request is made.
• Standard internal appeals are typically reviewed and decided within 15 to 30 days, depending on your insurer’s policy and whether the service has already been received.
• If your appeal moves to an external review, the decision is usually issued within 45 days of the request being accepted.
• For urgent medical situations, you can request an expedited (fast) appeal, which should be resolved within 72 hours or sooner, depending on the severity of your condition.

Always check your insurance plan's specific deadlines and keep track of any communication or paperwork to ensure you stay within the required time frames.

What to Do If Insurance Denies Authorization for Specific Services

Medications: Ask your provider to submit documentation showing you tried other treatments first. Request a formulary exception if the drug isn’t on the approved list.

Surgery or Diagnostic Imaging: Submit imaging reports and specialist evaluations. Make sure coding and documentation fully align with the insurer’s criteria.

Physical or Mental Health Therapy: Provide a treatment plan outlining frequency, goals, and progress. Ask your therapist or psychiatrist for a letter of medical necessity.

Durable Medical Equipment (DME): Document your daily needs and how the DME improves function or quality of life.

How to Escalate a Denial

If your appeal is denied, you can:

• Request an external review through your state insurance department or health exchange.
• Contact your state’s Department of Insurance or a consumer assistance program.
• Ask your employer’s HR or benefits department to intervene, if you have employer-sponsored insurance.

Your Rights in the Appeals Process

The appeals process may vary depending on your type of coverage.

For Private Insurance Plans

Under the Affordable Care Act (ACA), most private health insurance plans must offer a two-level appeals process: an internal appeal followed by an external review if the denial is upheld.

You have the right to:

• Receive a written explanation of a denial
• File an internal appeal within 180 days
• Request an expedited appeal if waiting would seriously harm your health
• Seek an independent external review if your appeal is denied

Your insurer must provide instructions with each denial notice, and internal appeals are typically resolved within 30–60 days. External reviews are generally completed within 45 days, or sooner for urgent cases.

External reviews are handled either by your state insurance department or the federal government via the HHS-administered external review process. For full details, visit HealthCare.gov’s appeals page.

For Medicare Beneficiaries

Medicare enrollees—whether in Original Medicare (Part A or B), a Medicare Advantage plan (Part C), or a Medicare drug plan (Part D)—have the right to appeal if coverage or payment is denied.

You have the right to:

• Receive a written denial notice explaining the decision
• File an appeal within 60 to 180 days, depending on your plan
• Request an expedited (fast) appeal if your health could be harmed by delay
• Continue to higher levels of appeal if the initial decision is upheld

While these rights apply across all Medicare types, the appeal steps and timelines vary slightly between Original Medicare, Advantage plans, and drug plans. Your denial notice will include specific instructions.

For more information:

• Original Medicare appeals
• Medicare Advantage appeals
• Medicare Part D drug plan appeals

Or call 1-800-MEDICARE for help.

What Medicare Covers

If you’re a Medicare beneficiary, your plan may cover many services related to the appeal process:

• Physician visits to discuss appeal options
• Second opinions for surgery or major treatments
• Genetic or specialist counseling
• Home health assessments to justify durable medical equipment
• Telehealth consultations for peer-to-peer reviews or specialist input

Medicare Advantage plans may have different rules—check your plan’s prior authorization and appeal policies carefully.

How to Stay Proactive to Avoid Future Denials

While denials can’t always be prevented, a few steps can reduce your chances of facing one again:

• Ask early if a prior authorization is required. Don’t assume—it varies by plan, provider, and service.
• Confirm your provider is in-network. Many denials happen simply because the provider wasn’t covered under your plan.
• Double-check codes and documentation. Even small administrative errors (like the wrong CPT code) can result in denials.
• Keep your own records. Hold onto denial letters, test results, and copies of past appeal documents.
• Have your provider note urgency. When appropriate, ask your doctor to preemptively include urgency or justification in initial requests.

If you’ve had a denial before, a patient advocate can help you build a more airtight request next time—before care is delayed.

Patient Advocates Can Help

Facing a prior authorization denial can feel overwhelming—especially when you're focused on your health. That's where Solace patient advocates come in.

Solace provides experienced professionals who:

• Help you understand your insurance denial and your appeal options
• Work directly with doctors to coordinate medical documentation
• Draft and submit appeal letters on your behalf
• Communicate with insurers to escalate your case when needed
• Support families facing complex or chronic health conditions

You don’t have to face insurance hurdles alone. Solace advocates are here to help you cut through the red tape and take control of your care.

FAQ: Frequently Asked Questions About Prior Authorization Denials

What steps should I take if my prior authorization is denied by insurance?

If your prior authorization is denied, request a copy of the denial letter from your insurance company. This document will explain the reason for the denial and outline your rights to appeal. Speak with your healthcare provider about the denial to clarify any medical or administrative issues. From there, you can either request a peer-to-peer review or begin the formal appeals process, which may involve submitting a written appeal and additional supporting documentation.

How do I appeal a denied prior authorization request?

To appeal a denied prior authorization, you or your provider must submit a written request to your insurance company. This appeal should include a clear explanation of why the treatment or service is medically necessary, backed by your medical records, a letter of medical necessity from your provider, and any other relevant documents. Appeals must usually be submitted within a specific time frame—often 60 to 180 days from the date of denial—so it’s important to act quickly.

What are common reasons why prior authorization requests are denied?

Prior authorization denials commonly occur due to incomplete documentation, coding errors, lack of medical necessity as interpreted by the insurer, or the use of out-of-network providers. Other reasons include the requested service not being a covered benefit under the plan or the insurer requiring that other treatments be tried first. Denials can also result from missing lab results, physician notes, or outdated medical information.

What information is needed for a prior authorization appeal?

An effective appeal typically includes the original denial letter, a detailed statement from your provider explaining the necessity of the requested service, your full medical history relevant to the request, diagnostic test results, and supporting clinical guidelines when applicable. Including CPT or ICD-10 codes and treatment records can help clarify why the requested care is appropriate for your condition.

How long does it take to appeal a denied prior authorization?

The timeframe varies by insurance plan, but most insurers must respond to standard appeals within 30 days. Expedited appeals—typically for urgent medical situations—are often resolved within 72 hours. External reviews, requested if your internal appeal is denied, can take up to 45 days. It’s important to follow up regularly with both your provider and your insurer throughout the process.

Can a doctor help with a prior authorization denial appeal?

Yes, your doctor plays a crucial role in the appeals process. They can participate in a peer-to-peer review with the insurer’s medical reviewer to argue for the medical necessity of your treatment. Additionally, they can provide a detailed letter of medical necessity and help ensure that all documentation is submitted correctly. Many appeals are overturned when a provider is actively involved.

What should I do if my insurance denies prior authorization for surgery or medication?

If surgery or medication is denied, your provider should first verify whether the proper documentation and codes were submitted. You may request a peer-to-peer review or initiate a written appeal that includes medical records, treatment history, and justification for why the specific medication or surgery is necessary. In some cases, formulary exceptions or second opinions may support your case.

What is a peer-to-peer review in the prior authorization process?

A peer-to-peer review is a phone conversation between your treating physician and a medical reviewer from your insurance company. It provides an opportunity for your doctor to explain the clinical necessity of your treatment and respond to any concerns raised in the initial denial. These reviews often result in faster resolutions and increased chances of approval without going through a lengthy formal appeal.

How can I find out why my prior authorization was denied?

You can find out the reason by reviewing your denial letter, which should list a specific denial code and explanation. If the letter is unclear, call your insurance company and ask for clarification. Your provider’s billing or referral coordinator can also assist in decoding the denial reason and advising on next steps. Understanding the exact issue is critical for crafting a successful appeal.

How can a patient advocate help with a prior authorization denial?

Patient advocates can guide you through the appeals process, help you understand your insurance plan and rights, and communicate with your healthcare provider and insurer on your behalf. They’re experienced in gathering documentation, drafting appeal letters, and escalating denials when necessary. If you're overwhelmed by the process or facing delays in care, working with a patient advocate can make a significant difference in the outcome.

This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.

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