What to do
Get the plan's criteria into your clinicians' hands, in writing
A letter written against the plan's own standard beats a warm letter of support every time, and a clinician cannot write to a criterion they have never read. Send the medical policy by name and number, and ask them to answer it point by point in the order the policy uses.
Fix the codes before submission, not after
Ask the clinic which CPT codes are going in, and check them against what the plan's policy covers. A mismatch between the code submitted and the code the policy names is a denial that looks clinical and is actually clerical.
Get the letters early and check they have not expired
Letters are often treated as current only within a window of the submission date, not the surgery date, and a letter that ages out mid-process delays everything. Ask what your plan's window is and count from the date the request goes in.
Say plainly if waiting would harm you, and get a physician to say it
Urgency is not a mood, it is a category with its own faster timeline. Under 29 CFR 2560.503-1(m)(1)(iii), where a physician with knowledge of your condition determines a claim is urgent, it SHALL BE TREATED as urgent — the plan does not get to substitute its own view. Ask your clinician to state that determination in the request itself.
Confirm receipt, then confirm the clock
Ask the plan to confirm it has the request and to tell you the date it must decide by. Both answers in writing. This is the cheapest step here and the one that most often turns up a request nobody received.
Ask about the network in the same breath
Approval and network are separate questions and people discover that at the worst moment. Ask whether the surgeon, the facility, the anaesthesiologist and the assistant surgeon are all in network for this procedure. If any is not, the argument to make is a network one and it is better made now.
The things that look helpful and are not
Volume does not help. A thicker file with the same clinical content does not change a reviewer's answer, and it buries the paragraphs that do.
Nor does personal testimony, at this stage. It matters enormously and it belongs in your life, but a prior-authorization reviewer is applying written criteria and cannot approve on sympathy. Save it — there are later stages, and some regulators, where it counts.
What moves a pre-service decision is narrow: the plan's own criterion, answered specifically, by someone qualified to answer it, with the documentation the criterion names.
Start the record now, even though nothing has gone wrong
Every call, with the date, the name, and the reference number. It feels like paranoia until the first time a plan says something was never received, and then it is the only reason you can prove otherwise.
This is the same log the appeal pages ask for, built months earlier and far more cheaply. If you are never denied, you have lost an hour. If you are, you start the appeal with a record nobody can dispute.
Common questions
- Is there anything I can do if my plan simply excludes this care?
- Yes, and it is a different argument from medical necessity — it turns on whether the exclusion is lawful for your plan type, which depends on who regulates your plan. Sort your plan type first; the answer changes completely between a self-funded private employer plan and a fully insured one.
- Should I get a second surgeon's opinion before submitting?
- Not for its own sake. It helps when the plan's criteria ask for something your surgeon cannot speak to, or when you may need to show that no in-network provider can do the procedure. Otherwise it adds time without adding an answer.
- How much of this can I skip if I am short on time?
- Do three: send the criteria to your clinicians, confirm the plan received the request and by when it must decide, and write down every call. Those three cost very little and cover the failures that are hardest to recover from.
Where to go next
Sources for the legal points on this page
- If a treating physician says the claim is urgent, the plan must treat it as urgent
Federal — ERISA-governed group health plans · effective in force
29 CFR 2560.503-1(m)(1)(iii) (physician determination controls), read against (m)(1)(ii) (otherwise a prudent-layperson standard applied by the plan) and (m)(1)(i) (what makes a claim urgent)
Status: settled · source-checked 2026-08-09 · primary source verified: 2026-08-09 (govinfo CFR XML, 2025 edition)
Also on this page, without a citation yet
- That any of these steps improves the likelihood of approval. They are drawn from how coverage decisions are structured and from what denials most often turn on, not from published outcome data. No page on this site can promise an approval.
These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.