Build your case
Find the rules and evidence that support you
Find the plan's medical policy, your plan's own wording, and the guidelines and studies that back the treatment.
Do this today
- Use the tool: Evidence checklist builder Get a tailored list of the documents that answer your denial reason, and who holds each one.
- Read: How to find the insurer's medical policy for your treatment 5 minute read. Ask for the clinical rule your plan used to deny your care, find out which version applied, and check it against your records. Covers what a denial notice must say and what you can request for free.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- If the plan relied on an internal rule, guideline or protocol, the denial notice must either set it out or say that a copy is free on request.
- For a denial based on medical necessity or on experimental treatment, the notice must either explain the clinical reasoning or say the explanation is free on request.
- The federal claims rule gives no number of days for these requests. Ask for a reply before your appeal is due and keep proof of when you asked.
- Medicare Advantage plans must follow Original Medicare's coverage rules and post any criteria they write themselves.
Read the full guide: How to find the insurer's medical policy for your treatment
More guides, tools and letters
More guides, tools, letters 9
Guides
- How to find clinical guidelines and studies
Work with your doctor to find the guidelines and studies that back your treatment, and use them to answer the plan's reason. Covers experimental denials, past review decisions and how to cite evidence.
- How to find the insurer's medical policy for your treatment
Ask for the clinical rule your plan used to deny your care, find out which version applied, and check it against your records. Covers what a denial notice must say and what you can request for free.
- Using your plan's own words
Quote the plan's own definitions, exclusions and criteria back to it in your appeal. Covers where to find them, how to quote them accurately, and what to do when the plan's documents work against you.
Tools
- Tool
Evidence checklist builder
Get a tailored list of the documents that answer your denial reason, and who holds each one.
Letters and scripts
- Letter or script
Ask for the clinical criteria used
A written request for the internal rule, guideline or clinical explanation the plan used to deny your care, so your appeal can answer it point by point. It is a records request, not an appeal.
Programs and services
- Program or service
California Independent Medical Review decision search
A searchable database of every California Independent Medical Review decision since 1 January 2001. Search by drug, treatment, therapy or condition to read how reviewers decided cases like yours.
From California Department of Managed Health Care
- Program or service
KFF analysis: claims denials and appeals in marketplace plans in 2024
KFF's analysis of federal data on claims denied and appealed in HealthCare.gov plans in 2024. It reports that 19% of in-network claims were denied. It is a source of statistics, not a how-to guide.
From KFF
- Program or service
New York external appeals searchable archive
A database of closed New York external appeals decided on or after 31 May 2019. Filter by diagnosis, treatment, health plan, decision and year to see outcomes of similar cases.
From New York State Department of Financial Services
- Program or service
Washington independent review decision search
A state search of independent review decisions Washington has collected since 2016. Results show the insurer, diagnosis and treatment, the outcome and the reviewer's reasoning.
From Washington State Office of the Insurance Commissioner
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
Not what you need? Find a person who can help, or search the whole site.