Appeal: prior authorization denied
Asks your plan to reverse a refusal of approval before care, to say what standard it applied, and to decide with a clinician in the right field.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan refused to approve care before you had it, or denied a claim because no approval was in place. Attach the denial notice and your doctor's request.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: prior authorization denied Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] that denied prior authorization, which is approval before care, for [The care or drug that was denied] from [Doctor, hospital or pharmacy], planned for [Planned date of the care]. I ask you to reverse that decision and approve this care under [Name of the health plan], member ID [Member ID].
Approval was requested on [Date approval was requested] by [Who asked the plan for approval]. The plan's reference number is [The plan's reference number for the request]. The plan's reason for denying it was: [The reason the plan gave]
Why I need this care: [Why you need this care] My treating doctor is [Your treating doctor's name and specialty].
I ask the plan to show which plan provision or clinical criterion it applied, and how it applied it to my records. If the reason is that information is missing, I ask you to tell me and my doctor exactly what is missing and to give us a fair chance to send it before you decide.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), a request for approval before care is a claim for a benefit, and I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. Because the denial rests on a medical judgment, I also ask that you consult a health care professional with training and experience in the field of my condition who was not consulted on the first decision. Please consider every record and comment I send, including anything that was not before the first reviewer.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will ask for external review by an independent organization and may complain to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter 2. My doctor's request for approval 3. Relevant pages of my medical records 4. Letter from my treating doctor, if I have one
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter
- My doctor's request for approval
- Relevant pages of my medical records
- Letter from my treating doctor, if I have one
What happens next
- Your plan must decide within 30 days after it receives your appeal if the care has not happened yet, or within 60 days if you have already had it. If your plan has two appeal levels, each level gets half that time. Check the date on your notice, which controls.
- If waiting could seriously harm your health, ask your doctor to tell the plan the request is urgent, and switch to the request for an expedited appeal. An urgent appeal must be decided as soon as possible and within 72 hours.
- If the plan says no again, or does not answer in time, ask for external review (also called independent review), which is a review by reviewers outside the plan. For most job-based and individual plans you have at least four months after you receive the final denial to ask. Check the date on your notice, which controls.
- You can also complain to the agency that oversees your plan. Filing a complaint is not a substitute for an appeal, so file the appeal first and by the date on your notice.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Prior authorization denied
Your doctor asked the plan to approve care in advance and the plan said no. The clocks are short, and your doctor can ask for a doctor-to-doctor call. Independent external review is open if the reason is medical and your plan is not grandfathered.
- Denial reason
No prior authorization
The plan says approval was needed before the service and was not obtained. Find out whether approval was really required, who was supposed to ask, and whether getting it was impossible. Your provider often has to act.