Module V · Advocacy
Why 'no' is rarely the final answer — and how to fight back
Health insurance companies routinely deny claims and prior authorization requests. A KFF analysis of HealthCare.gov Marketplace insurers found that 17% of in-network claims were denied in 2021. Other data suggests denial rates are climbing, with one major insurer's denial rate jumping from 17% in 2023 to 25% in 2024.
These denials are often generated by automated algorithms rather than medical professionals. The goal is cost containment. When a claim is denied, the patient is left with a massive bill or, worse, a delay in necessary treatment. The emotional toll of fighting an insurance company while battling a serious illness is immense — but the fight is almost always worth having.
The most important fact to understand about insurance denials is that they are frequently overturned on appeal. Data indicates that when prior authorization denials are appealed, 80% of those appeals are successful. Despite this high success rate, the vast majority of patients never file an appeal — they simply give up or pay out of pocket.
Patients must view an initial denial as the beginning of a negotiation, not the end of the road. The first step is to demand the specific reason for the denial in writing. Insurance companies are legally required to provide this. Often, the denial is due to a simple coding error or a missing piece of documentation from the doctor's office.
Step 1 — Gather the Evidence: Request your complete medical records and the clinical guidelines the insurance company used to deny the claim.
Step 2 — Engage the Doctor: Your doctor's office must be your partner in this fight. Ask them to write a 'Letter of Medical Necessity' that explicitly addresses the reason for the denial and cites peer-reviewed literature supporting the treatment.
Step 3 — File the Internal Appeal: Submit the appeal within the required timeframe, keeping meticulous records of every phone call, email, and document sent.
Step 4 — Request an External Review: If the internal appeal is denied, you have the right under the Affordable Care Act to request an independent external review by a third-party medical expert. This review is binding on the insurance company.
Case Study
David was prescribed a specialized biologic medication for severe Crohn's disease. His insurance company denied the prior authorization request, stating he had not first tried and failed a cheaper, older medication — a practice known as step therapy. David was devastated and assumed he would have to suffer through months of ineffective treatment. His wife, acting as his advocate, refused to accept the denial. She requested the specific clinical guidelines the insurer used, then worked with David's rheumatologist to draft an appeal letter. The letter clearly documented that David had, in fact, tried the older medication five years ago while under the care of a different doctor, and it had caused liver toxicity. Because this detail was buried in an old paper file and not in the current electronic record, the insurance algorithm had missed it. The appeal was approved within 48 hours.
Self-Reflection Questions
Have I ever paid a medical bill that I suspected should have been covered by insurance?
Do I know the difference between an internal appeal and an external review?
Am I keeping a detailed log of every interaction I have with my insurance company?
Questions to Ask Your Provider
"If my insurance denies this prior authorization, what is your office's standard procedure for filing an appeal?"
"Can you provide me with a Letter of Medical Necessity that specifically addresses the insurance company's criteria?"
"Are there any patient assistance programs or manufacturer coupons available if the appeal is ultimately denied?"