How to Appeal a Prior Authorization Denial for Your Medication

Why Your Medication Was Denied - And What to Do Next

You got the letter. Your insurance denied coverage for your prescription. The drug your doctor prescribed - the one that actually works for you - is now off-limits. You’re stuck. You can’t afford to pay out of pocket. You can’t switch to another drug without risking your health. And now you’re told you have to appeal to get it back.

This isn’t rare. About 6% of prior authorization requests get denied in the U.S. every year. That’s over 18 million times. But here’s the part no one tells you: 82% of those denials get reversed when you appeal. Most people don’t even try. They give up. But you don’t have to.

Step 1: Read the Denial Letter - Don’t Just Throw It Away

The letter your insurer sent isn’t just a rejection. It’s a roadmap. It tells you exactly why they said no. There are three main reasons they give:

• Incomplete paperwork (37% of denials)
• They don’t think it’s medically necessary (48%)
• The drug isn’t covered by your plan (15%)

Don’t guess. Find the exact wording. Look for phrases like “lack of clinical documentation” or “alternative therapies preferred.” Write it down. You’ll need to answer each point directly in your appeal.

If you didn’t get a written denial, call your insurer right away. Ask for a formal denial letter. Self-insured plans often delay sending it - but you still have rights. Without this letter, you can’t appeal.

Step 2: Gather Every Piece of Medical Evidence

Insurance companies don’t make decisions based on your word. They need proof. Your doctor’s note isn’t enough. You need:

• Full medical records from your provider
• Lab results showing your condition
• Previous treatment failures - with dates and outcomes
• A letter from your doctor explaining why this drug is necessary
• CPT and ICD-10 codes that match your diagnosis and treatment

Here’s what works: A patient on Humira was denied because the insurer said they hadn’t tried “other biologics.” But the patient’s records showed they’d tried three others over 14 months - all failed. They included a 2-page timeline with exact dates, side effects, and lab numbers. The appeal was approved in 7 days.

Doctors often miss this: 63% of successful appeals include documented treatment failures. Not just “I tried something else.” Specifics. Names. Dates. Results. That’s what moves the needle.

Step 3: Know Your Insurer’s Rules - They Vary Wildly

Every insurer has different rules. CVS/Caremark wants appeals faxed to 1-888-836-0730. UnitedHealthcare requires online portal submissions. Kaiser Permanente uses a different form than Anthem. Miss the method, and your appeal gets tossed - no second chances.

Check your plan’s website. Search for “prior authorization appeal process.” If you can’t find it, call their provider relations department. They handle these daily. 76% of submission issues get fixed just by talking to them.

Also check deadlines. You typically have 180 days from the denial date to file. But don’t wait. The sooner you start, the sooner you get your meds.

Step 4: Write a Clear, Direct Appeal Letter

Your letter is your strongest tool. It’s not a plea. It’s a clinical argument.

Use this structure:

1. State your intent: “I am formally appealing the denial of [drug name] for [patient name].”
2. Quote the denial reason: “Your letter states the drug was denied due to lack of medical necessity.”
3. Answer it with facts: “This is incorrect. My records show I’ve failed three alternatives: [Drug A] caused severe nausea and was discontinued on [date]. [Drug B] reduced my symptoms by only 15%. [Drug C] triggered an allergic reaction.”
4. Reference their own guidelines: “According to your 2024 Preferred Drug List, [drug name] is listed as a preferred option for [condition] after two failed therapies - which I’ve met.”
5. Include your doctor’s statement: Attach their letter. Make sure it says “medically necessary” and “no safer or equally effective alternative exists.”

Doctors who write these letters see 32% higher success rates. Why? Because insurers trust clinical expertise - not patient emotion.

Step 5: Get Your Doctor Involved - It’s Not Optional

Your doctor isn’t just a signature on a form. They’re your advocate. But most don’t know how to write an effective letter.

Give them this prompt: “Please write a letter stating that [drug name] is medically necessary because I’ve failed at least two alternatives, and the risks of not taking it outweigh the risks of the drug. Cite my specific history and your clinical judgment.”

Some insurers let doctors call in directly. Ask your provider’s office if they can speak to the medical reviewer. That call can cut weeks off the process.

One patient’s rheumatologist called UnitedHealthcare’s medical director after the appeal was denied. The director reviewed the file, saw the treatment history, and approved the drug within 48 hours.

Step 6: Track Everything - And Follow Up

Insurers say they’ll respond in 30 days. They often don’t. That’s why 44% of appeals need resubmission - not because they’re wrong, but because they got lost.

Keep a log:

• Date you mailed/faxed/uploaded the appeal
• Who you spoke to (name, ID, date, time)
• Reference number
• Next follow-up date

Call every 5-7 business days. Ask: “Has my appeal been assigned to a reviewer?” “Can you confirm it’s in the system?”

Don’t let them ghost you. The average physician spends 1-2 hours per week just handling prior auth appeals. You’re not alone. Pushing back is part of the job.

What If Your Appeal Gets Denied Again?

If the first appeal fails, you have two options: a second internal appeal or an external review.

For a second internal appeal, add new evidence. Maybe you got a second opinion. Maybe your condition worsened. Include updated records.

For an external review, you have 365 days from the final denial to request it. This means an independent doctor - not your insurer - reviews your case. This is your last chance before legal action.

Medicare Advantage plans have faster timelines - they must respond within 72 hours. Commercial plans? Not so much. But external reviews often overturn denials in over 70% of cases.

Why So Many Appeals Succeed - And Why Most People Fail

Here’s the truth: 41% of initial denials are due to simple paperwork errors. Miss a code. Leave out a date. Use the wrong form. That’s it.

People fail because they treat this like a formality. They write a vague letter. They don’t attach the right documents. They wait too long.

But if you follow the steps - read the denial, gather the records, write a targeted letter, get your doctor on board, and track every step - your odds jump from 11% (the percentage of people who appeal) to over 80%.

What’s Changing in 2025

The system is slowly getting better. CMS now requires Medicare Advantage plans to respond to prior auth requests in 72 hours - down from 14 days. That’s cutting appeal needs by 18%.

Also, the CAQH Prior Authorization Clearinghouse is rolling out in 2025. It’s meant to standardize forms and reduce errors by 27%. That means fewer denials from simple mistakes.

But here’s the catch: as more drugs become specialty medications, insurers are tightening rules. More denials. More appeals. You need to be ready.

Final Tip: Don’t Wait Until You Run Out

Start the appeal the day you get the denial. Don’t wait for your refill to run out. Don’t wait to see if your doctor will help. Don’t wait to “feel better.”

Every day you delay is a day without your medication. And that’s when things get dangerous.

You’ve already done the hard part - you’re taking your meds. Now fight for your right to keep taking them. You’re not asking for a favor. You’re exercising your right under the Affordable Care Act and ERISA.

And remember: 82% of appeals succeed. You’re not the exception. You’re the rule - if you do it right.