Receiving a medication denial can feel final. In many cases, it is not. Patients generally have the right to ask their health plan to reconsider a coverage decision. Depending on the type of plan and denial, the case may also qualify for review by an independent third party.
The appeal will be stronger when it directly addresses the reason given in the denial notice. Here is an eight-step process for building one.
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Obtain the Written Denial
Ask for a copy of the denial letter if you have not received one. The letter should identify:
- The medication that was denied
- The reason for the decision
- The coverage requirement that was not met
- How to file an appeal
- The appeal deadline
- Where supporting information should be sent
- Whether an urgent review is available
Do not rely only on a verbal explanation. The written notice contains the language that the appeal needs to address.
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Determine the Exact Reason for Denial
Common reasons include: prior medications were not tried; previous treatment failures were not documented; the medication is non-formulary; the requested dose or quantity exceeds plan limits; the diagnosis does not meet the coverage criteria; required laboratory results were not submitted; the request did not come from the appropriate specialist; the plan considers another medication preferred; or records were incomplete.
An appeal that discusses the patient's general need for treatment but ignores the specific denial reason may miss the target.
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Contact the Prescriber
Give the prescriber's office a copy of the denial letter. Ask whether the office can submit: relevant progress notes, previous medication names, dates and durations of previous treatment, reasons treatments were discontinued, documented adverse effects, laboratory or diagnostic findings, clinical justification for the requested dose, or an explanation of why covered alternatives are inappropriate.
The prescriber should explain the medical reasoning clearly and connect it to the plan's stated requirement.
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Verify the Patient's Treatment History
Create an accurate timeline of treatments that were tried, including medication name, strength and dose, approximate start and stop dates, treatment response, side effects, reason for discontinuation, and pharmacy where it was filled.
Health plans may sometimes see paid pharmacy claims, but claims do not always tell the entire clinical story. A claim may show that medication was dispensed without showing whether it worked, caused side effects, or was actually taken.
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Ask Whether a Formulary Exception Is Appropriate
When the requested medication is not on the plan's formulary, the prescriber may be able to request an exception. A strong exception request explains why the covered alternatives were already tried and failed, caused unacceptable adverse effects, are contraindicated, are expected to be ineffective, or would create a meaningful clinical risk.
HealthCare.gov states that patients may appeal when an insurer will not pay for a prescription and may be able to have the decision reviewed independently.1
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Request an Urgent Review When Appropriate
An expedited review may be available when waiting for the standard process could seriously jeopardize the patient's health, ability to function, or recovery. Urgency should be based on the patient's clinical circumstances, not simply inconvenience or frustration. The prescriber may need to certify why a faster decision is medically necessary.
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Submit the Appeal Before the Deadline
Follow the instructions in the denial letter carefully. Keep copies of the appeal form, the denial letter, medical records, the prescriber's supporting statement, fax confirmations, portal-submission receipts, mailing records, and reference numbers.
Write down the date the appeal was submitted and when a decision is expected.
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Follow Up
Call the plan to confirm that the appeal was received and is complete. Ask: Has the appeal been entered into the system? Are any records missing? What level of appeal is being reviewed? When is the decision due? How will the patient and prescriber be notified? Is an external review available if the appeal is denied?2
What Makes an Appeal Stronger?
A persuasive medication appeal is specific, documented, and connected to the denial reason. It should answer three central questions:
- Why does this patient need the requested medication?
- Why are the plan's preferred options ineffective, unsafe, or inappropriate?
- What medical records support those conclusions?
Emotion may explain why the decision is important. Documentation explains why it should be changed.
The Bottom Line
A denial is a decision based on the information reviewed at a particular point in time. Read the letter, identify the unmet requirement, gather the relevant records, and make sure the appeal directly addresses the health plan's reason for denial.
Frequently Asked Questions
How long do I have to file an appeal?
The deadline is stated in your denial letter and varies by plan and benefit type. Note the date as soon as you receive the letter, since missing the window can end your appeal rights for that decision.
What if my appeal is denied again?
Many plans offer multiple levels of internal appeal, and some denials qualify for an independent external review by a party outside the insurance company. Your denial letter should describe what's available at each stage.
Can my prescriber file the appeal for me?
Often yes, especially for the clinical portions. Many plans also allow patients to authorize a prescriber or other representative to handle the appeal on their behalf.
A strong appeal answers the plan's specific denial reason — not just "why the patient needs the drug." Read the letter twice before you write anything.
References
- HealthCare.gov. Internal appeals and external review. healthcare.gov/appeal-insurance-company-decision/internal-appeals
- HealthCare.gov. External review of a denied claim. healthcare.gov/appeal-insurance-company-decision/external-review
- Centers for Medicare & Medicaid Services. HHS-Administered Federal External Review Process. cms.gov/CCIIO