Four in five appealed prior authorization denials in Medicare Advantage were overturned in 2024. About one in nine was appealed. Here is a letter you can copy.
Write it the way you would explain the case to another clinician. Name the denial and quote the insurer’s reason. Answer that reason with the chart: what you found, what you already tried and for how long, and why the patient needs this now. Attach the notes that prove it, and send it before the deadline on the denial notice.
Is it worth appealing?
Usually. In 2024, Medicare Advantage insurers fully or partially denied 4.1 million prior authorization requests. Only 11.5% of those denials were appealed, and 80.7% of the appeals were partially or fully overturned.
The odds are better than they feel. In an American Medical Association survey of 1,000 physicians, 18% said they always appeal a prior authorization denial. Of the rest, 62% did not expect an appeal to work, 48% said the patient could not wait, and 48% did not have the staff time.
Marketplace plans are harder. In 2024, insurers on HealthCare.gov denied 19% of in-network claims. Fewer than 1% of those denials were appealed, and insurers upheld 66% of the ones that were. Those appeals were filed by patients, and the same letter works for them.
What goes in the letter?
Four parts, in this order. A reviewer reads the opening and decides how closely to read the rest.
Who and what. The patient’s name, date of birth and member ID, the claim or authorization number, the date of service, and the service with the codes you billed.
The denial, in their words. Quote the reason from the denial notice, then say in one sentence that you are asking them to reconsider.
Your reasoning. The history, what you found on exam, what you already tried and for how long, and why this is needed now. If the plan publishes criteria for the service, match your facts to them one by one.
The proof and the ask. List what you attached: visit notes, results, records of earlier treatment, the plan’s own policy. Ask for approval, and ask for a peer-to-peer call if the plan offers one.
The template
Copy it, fill in the brackets, and cut anything that does not answer the reason on the notice.
[Date]
[Insurer], Appeals. [Address or fax number from the denial notice]
Re: Appeal of [prior authorization / claim] denial, reference [number]
Patient: [name]. Date of birth: [date]. Member ID: [number].
Service: [service] ([CPT or HCPCS codes]) for [diagnosis] ([ICD-10 codes]). Date of service: [date, or requested].
I am writing to appeal your denial dated [date] of [service] for my patient, [name]. Your notice gives the reason as “[quote it exactly].” I am asking you to reconsider.
[Name] is a [age]-year-old with [condition] since [when]. [One or two sentences of history that bear on this decision.] On examination on [date], I found [the findings that support the request].
We have already tried [treatment] for [duration] and [treatment] for [duration], with [result]. [If the plan requires other steps first, say which ones you completed and when.]
[Service] is needed now because [the clinical reason, in plain words]. [If the plan publishes criteria, name the policy and show how each one is met.] Without it, [what is likely to happen].
I have attached [visit notes from these dates], [results], [records of earlier treatment] and [the plan’s policy, if relevant]. Please approve [service]. If a reviewer disagrees, I request a peer-to-peer discussion with a physician in the same or a similar specialty. You can reach me at [phone] or [email].
Sincerely,
[Name, credentials], [practice], NPI [number]
How long do I have?
The deadline is printed on the denial notice, and it wins over anything here. The usual windows:
Medicare Advantage: 65 days from the date on the denial notice. For a service the patient has not had yet, you can request the reconsideration yourself. The plan has 30 days to decide on care not yet given and 60 days on payment. When waiting could seriously harm the patient’s health, it must decide within 72 hours.
Plans sold on HealthCare.gov: 180 days to file an internal appeal. The insurer has 30 days to decide on care not yet given and 60 days on care already given. If the case is urgent, the patient can file the internal appeal and an external review at the same time.
Other plans: employer and state plans set their own windows. The notice will say.
Why do appeals fail?
The letter argues in general terms. “Medically necessary,” without the facts that make it so, reads like a form letter.
It answers a different reason from the one on the notice.
The chart does not back it up. A reviewer reads the visit note, and a letter cannot add what the note left out.
The codes do not match the note. Check every code you keep, including the ones software suggested.
It arrives after the deadline.
Most appeals are won or lost on the day of the visit. If the note says why the care was needed, the letter only has to point to it. Medical necessity is rarely said aloud in full, so build it into your template.
Should I ask for a peer-to-peer?
If the plan offers one, yes. It is a conversation with the plan’s reviewing clinician, and it lets you answer the denial directly. Have three things in front of you: the reason on the notice, the two or three facts that answer it, and what you tried first. Ask for a reviewer in your specialty.
Frequently asked questions
Can I file the appeal, or does my patient have to?
Often you can. In Medicare Advantage, a doctor can request reconsideration of a service the patient has not had yet, and must tell the patient. For other plans, and for claims already denied, the notice says who can file.
What if the appeal is denied again?
Go to the next level. In Medicare Advantage, a denial the plan upholds goes to an independent reviewer automatically. For plans sold on HealthCare.gov, the patient can request an external review within 4 months of the final denial, and the insurer must accept the reviewer’s decision.
Is this legal advice?
No. Plans and states differ. Read the notice, and check your contract with the payer.
The short version
Answer the reason on the notice with facts from the chart, attach the proof, and send it before the deadline. In Medicare Advantage, four in five appeals of a prior authorization denial succeeded in 2024.
The price is on the page, not behind a call. Early access is open: solanto.ai/pricing
Send this to the colleague who wrote off a denial last month.
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