Denied but Not Defeated: How to Appeal an Insurance Denial—and Win

Did you know that according to a report published by the Kaiser Family Foundation, less than 1% of denied insurance claims are appealed—but more than 50% of those that are, actually succeed? That stat alone should give every patient hope. It’s a reminder that when insurance says “no,” that doesn’t mean the fight is over. In fact, it’s often just the beginning.

Whether you're living with a chronic rheumatic condition  or supporting someone who is, knowing how to navigate an insurance denial can make a major difference in your care. If you’ve been denied coverage for a treatment your doctor says you need, don’t give up. Here’s a clear, step-by-step guide to help you push back and take charge of your health.

Step 1: Understand Why You Were Denied

Before you can fight a denial, you need to know what you're fighting. Start by carefully reviewing the denial letter. If you did not receive a denial letter, request it from your insurance provider—under federal law, you have the right to obtain a written explanation of benefits (EOB) or denial notice detailing why your claim was denied. This should include:

• The reason your claim was denied
• The insurance policy provisions involved
• Instructions on how and when to appeal

Common reasons for denials include:

• "Lack of medical necessity"
• Missing pre-authorization
• Incorrect billing codes
• The treatment is not covered under your plan

Step 2: Gather Your Evidence

You’ll need strong documentation to build your case. Collect:

• The denial letter
• Your insurance policy (highlight relevant sections)
• Medical records and test results, including all previous treatments or medications for the condition
• A letter of medical necessity from your healthcare provider
• Any past correspondence with your insurer

Tip: Keep everything in one folder—physical or digital—for easy access.

Step 3: Write a Strong Appeal Letter

A clear, organized letter can make all the difference. Be sure to:

• Include the basics: Name, policy and claim numbers, and date of denial.
• State your request: Clearly write you are appealing the denial of coverage.
• Explain the need: Describe the treatment, why it’s medically necessary and previously tried treatments (if any), supported by documentation and your provider’s input.
• Cite policy language: Point out where your insurance policy supports your case.
• Attach documents: Include everything you've gathered to back up your appeal.

Step 4: Submit and Follow Up

Appeals usually need to be submitted by mail, fax or online. Follow the exact process outlined in your denial letter—and do it within the deadline. After submitting:

• Confirm your appeal was received
• Keep a log of phone calls, emails, and contact names
• Know your timeline—some expedited cases must be reviewed in as little as 72 hours

Step 5: Escalate If Needed

If your initial appeal is denied, don’t stop there. You have more options:

• Request a peer-to-peer review: Ask for your provider to speak with a physician reviewer at the insurance company.
• File a complaint with your state insurance commissioner: Every state has a system to help consumers challenge unfair denials.
• Seek legal support: A health law attorney can assist with complex or high-stakes cases.

Tips for Success

• Be persistent. Appeals take time.
• Stay organized. Keep track of every document and deadline.
• Get support. Reach out to your rheumatologist’s office, as some practices offer a care coordination program and can help provide supporting documentation and key contacts. Services like Claimable can help you stay on track—or even do the heavy lifting by providing paid-for AI services.

Contributor: Kristina Kujan, CPC, CRHC, CPB; Coastal RCM