How to appeal a denied prior authorization

Most denials are appealable, and appeal windows are usually shorter than people expect. Here's what to actually do, in order, and what makes the difference between a form appeal and one that gets taken seriously.

Step by step

1. Read the denial notice for the deadline. Standard internal appeals are typically due within 60 days of the denial for most commercial and Medicaid managed-care plans, though your specific plan document controls. If your health could be seriously jeopardized by waiting, you can request an expedited appeal, which most plans must decide within 72 hours.
2. Get the specific reason and the criteria applied. A denial notice must state the reason; for medical-necessity denials, you're entitled to the specific clinical criteria or guideline the reviewer used. If it isn't in the letter, call and ask for it in writing before you draft the appeal.
3. Gather documentation that speaks to that exact criteria. Not just "more records", the specific clinical facts the criteria requires: a prior treatment that failed, a diagnosis code, a functional-status measurement, whatever the guideline actually asks for.
4. Ask your provider for a letter of medical necessity. A treating provider's letter that explicitly addresses the denial's stated reason carries more weight than a general note.
5. Write the appeal to the criteria, not the decision. State what was denied and why (citing the reason code and the guideline), then walk through how the documentation satisfies each element of that guideline.
6. Submit before the deadline, in writing, and keep a copy. If you submit online or by fax, keep the confirmation. If you don't hear back within the plan's required response window, follow up and cite the regulatory timeline.
7. If the internal appeal is denied, ask about external review. Most states provide an independent external review process, run by a party outside the plan, for medical-necessity denials that are upheld internally.

What actually moves the needle

Appeals succeed more often when they respond directly to the specific rule cited in the denial, not the general subject of the denial. If your plan's denial notice doesn't name a specific guideline, that's worth flagging explicitly in your appeal, since plans are generally required to identify the criteria they used for a medical-necessity determination.