What to do
Copy the four fields off your denial letter first
Claim number, date of the decision, the exact stated reason, and the appeal deadline. Everything else follows from these.
Work out your own deadline
Count forward from the date of the decision using the number of days your letter states. The federal floor for a group health plan is at least 180 days from receipt, so a letter stating less than that is worth questioning.
Answer the reason you were actually given
If it says not medically necessary, argue the criteria. If it says excluded, argue the exclusion. Answering the wrong one wastes the level.
Attach clinician letters that quote the plan's criteria
Ask your clinicians to reference the plan's own standard by name and state how you meet each element.
Send it so you can prove it arrived
Certified mail, the plan's portal with a saved confirmation, or fax with a transmission report. Keep the proof with the letter.
The letter
[Your name] · [Member ID] · [Claim or reference number] · [Today's date]
To: [Plan or insurer appeals address from your denial letter]
Re: Appeal of adverse benefit determination dated [date of decision], claim [number]
I am appealing the denial of coverage for [procedure or service, with CPT codes if you have them], denied on [date of decision] for the stated reason [quote the reason from the letter, word for word].
I am requesting: (1) that the determination be reversed and the service approved; (2) a copy of all documents, records, internal rules, guidelines, and clinical criteria relied on in making this determination; (3) the credentials and specialty of the reviewer who made it.
The determination should be reversed because [state your reason: the criteria are met and here is how; or the exclusion does not apply to this plan or this service; or the reviewer lacked relevant expertise].
Enclosed: [letters from clinicians, clinical records, the plan's own criteria, prior authorization correspondence].
If any part of this appeal is denied, please treat this letter as also requesting external review and provide the instructions and deadline for it.
[Signature] · [Phone] · [Address]
If waiting would harm you
Add one sentence near the top: I am requesting an expedited appeal because delay would seriously jeopardize my health or my ability to regain maximum function, specifically [reason: a surgical date will be lost, care will be interrupted]. Expedited timelines are much shorter.
Common questions
- How many days do I have?
- At least 180 days from receipt for a group health plan, under 29 CFR 2560.503-1(h)(3)(i). Your plan may give more but not less. Medicaid fair hearings are much shorter and run on state rules.
- Do I need a lawyer for this?
- Not for a first internal appeal on medical necessity. For a blanket exclusion, get help early.
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