What to do
Find the date of the decision, and note the date it arrived
You need both. The federal floor is at least 180 days from when you received the notice, but plans count from their own date, so working from the printed date keeps you safe either way.
Find the stated reason and classify it
Not medically necessary, cosmetic, experimental or investigational, excluded benefit, out of network, or a procedural problem such as missing prior authorization. Each has a different route.
Find the criterion or exclusion by name
A proper denial cites the medical policy, guideline, or plan provision it applied. If it does not, that is your first written question.
Find the appeal deadline and write it somewhere you will see it
This is the number that ends most cases. Put it in a calendar the day the letter arrives.
Find the external review instructions
They are usually near the end. They tell you what happens after the internal appeal and who conducts it.
Request the full file in writing
Ask for every document, internal rule, and clinical criterion relied on, plus the reviewer's credentials.
The distinction that decides your strategy
An exclusion denial says the plan never bought this benefit. A medical-necessity denial says your documentation did not meet a clinical standard. More clinical evidence fixes the second and does nothing for the first. Letters sometimes blur the two, so match the language against your plan document rather than trusting the summary.
Common questions
- The letter does not say which criteria were used. Is that allowed?
- You are entitled to the specific reason and to the rules relied on. Ask in writing. A vague denial is itself a point on appeal.
- Does the deadline run from the letter date or the date I received it?
- The federal rule for group health plans gives you at least 180 days from RECEIPT of the notification, not from the date printed on it. Plans count differently, so treat the printed date as your clock and you keep a safety margin. If it arrived very late, say so in writing.
Where to go next
Sources for the legal points on this page
- The ACA appeal framework: internal appeal, then binding external review
Federal — non-grandfathered group health plans and issuers · effective in force
29 CFR 2590.715-2719 — (b)(2)(ii)(B) urgent-care 72 hours, (b)(2)(ii)(F)(1) deemed exhaustion, (c)(2)(xi) state external review binding, (d)(2)(i) four-month federal external review window, (d)(2)(iv) immediate coverage on reversal; 29 CFR 2560.503-1 — (c)(2) no more than two appeals before civil action, (h)(3)(i) 180 days from receipt, (h)(3)(ii) independent reviewer, (h)(3)(iii) health professional on medical judgment
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06