Introduction: When the Letter Hits the Table
I still remember the first time I opened one of those dreaded envelopes from my insurance company. I was sitting at the kitchen table, boots still on after a long shift, with bills and kids’ school papers scattered everywhere. My wife slid me the envelope “It looks important.”
Inside: “Your request for prior authorization has been denied.”
Just like that, the shot my doctor said I needed wasn’t covered. The kicker? I’d already missed two days of work trying to schedule the appointment. That “no” wasn’t just paperwork. It was lost hours, more pain, and a whole lot of stress dumped on top of everything else.
If you’ve been there, you know how it feels like getting punched in the gut by a faceless corporation that doesn’t know you, doesn’t care, and sure as hell isn’t worried about your next shift.
But here’s the thing nobody tells you: that “no” isn’t the end of the road. You can fight back, and more often than not, you can win.
What Prior Authorization Really Means
Let’s start plain and simple. Prior authorization (sometimes called “pre-authorization”) is when your insurance company makes your doctor ask for permission before you can get a treatment, test, or medication. They say it’s to keep costs down and make sure the treatment is “medically necessary.”
Sounds reasonable, right? Except when it’s not.
Denials happen for all kinds of reasons:
- A box didn’t get checked.
- The insurance company wants you to try a cheaper drug first (called step therapy).
- The doctor’s office used the wrong billing code.
- They claim it’s “experimental” or “not medically necessary.”
Stat check: According to the Kaiser Family Foundation, 51% of insured adults had to deal with prior authorization in the past two years, and about 22% of them were denied at least once.
Doctors hate it too. The American Medical Association says physicians and their staff spend nearly 14 hours a week wrestling with insurance red tape. That’s time they’re not treating patients. That’s time you’re left waiting.
Can You Fight a Denied Prior Authorization? Absolutely.
Here’s the truth most folks don’t hear: you can fight a denied prior authorization, and the odds are stacked in your favor if you do.
Medicare Advantage data shows 81% of appeals end up approved but hardly anyone appeals in the first place. Why? Because people think it’s pointless. Or they’re too exhausted. Or they just don’t know how.
And that’s exactly how insurance companies win by betting you’ll just roll over.
Not anymore.
Step-by-Step: How to Fight Back After a Denial
1. Know Your Plan Like You Know Your Tools
You wouldn’t fix a truck with the wrong socket wrench. Same thing here different plans have different rules. Employer coverage, Marketplace insurance, Medicare Advantage, Medicaid they all play by their own rulebook.
First step? Dig out your Summary of Benefits and Coverage (SBC). Look for the section on appeals. Highlight the deadlines and procedures. This little booklet is your manual.
2. Partner With Your Provider They’re Your Heavy Hitter
Doctors hate prior authorizations almost as much as we do. Use that to your advantage.
- Ask your provider’s office to lead or at least back up the appeal.
- See if they’ll do a peer-to-peer review, that’s when your doctor speaks directly to an insurance medical director.
- Request a strong letter of medical necessity with clinical evidence attached.
3. Get Organized, Then Get Loud
Think of this like a job site where you don’t show up without your gear.
- Keep a binder or digital folder with every letter, call log, denial notice, and email.
- Write down who you spoke to, their job title, and the time of the call.
- Save your Explanation of Benefits (EOB) and any notes from your doctor’s office.
When you file your appeal, you’ll look like someone who has their act together. That matters.
4. Understand the Denial Don’t Swing Blind
Every denial letter has a reason. Break it down:
- “Not medically necessary” → Ask for specifics. What criteria are they using? Then counter with your doctor’s evidence.
- “Experimental or investigational” → Check your plan’s definitions. Sometimes they’re using outdated info.
- “Out of network” → Argue medical necessity if there’s no alternative provider.
“Eighty-one percent of appeals succeed but only if you fight back.”
5. Call, Clarify, Climb the Ladder
Pick up the phone. Stay calm. Ask questions. If you hit a wall, politely escalate.
- Start with customer service.
- Ask to speak with a supervisor.
- Push for a medical director.
Sometimes just resubmitting with the right code or extra info is enough. I’ve had denials flipped in 48 hours just by pressing the right buttons.
6. Appeal Like You Mean It
Now the real work begins.
- Internal appeal: Every plan has a process. Deadlines are usually 30 to 180 days. Follow it to the letter.
- External review: If they still say no, you may be entitled to an independent review by a third party. This is your ace in the hole insurers hate losing control.
Pro tip: Don’t just say “I need this.” Say:
“According to section X of my plan, this treatment should be covered. Here’s supporting documentation.”
Attach doctor’s letters, test results, and policy excerpts. It’s paperwork warfare but it works.
7. Use New Tools You’re Not Alone
The old way meant spending hours writing letters. The new way? Let tech help.
- Claimable: AI-powered service that drafts appeals.
- Fight Health Insurance: Free chatbot that guides you step-by-step.
- Counterforce Health: Brand new in 2025 free AI tools that write letters and even do follow-up calls with insurers.
Think of these as the power tools of the appeal process. Why use a hand saw when you’ve got a circular saw sitting right there?
8. Bring in Backup: Advocates, Regulators, and Even Social Media
If all else fails:
- File a complaint with your state insurance commissioner.
- Talk to your HR benefits manager if it’s employer coverage.
- Some hospitals and nonprofits have patient advocates who will fight for you.
- And yes, sometimes going public posting your story on Twitter or talking to a local reporter gets the insurer moving faster than any letter ever could.
Quick Tip: Ask your doctor for a peer-to-peer review. It’s one of the fastest ways to flip a denial.
Wrap-Up: Why This Fight Matters
Look, none of us asked to be experts in insurance red tape. We’ve got enough on our plates families to feed, jobs to keep, lives to live. But when an insurance company says no to something you and your doctor know you need, you’ve got two choices: take it lying down, or stand up and fight.
I’ve learned the hard way that persistence pays off. That binder of call logs, those letters, those long phone calls, they’re not just paperwork. They’re acts of standing up for your health, your family, and your right not to be steamrolled.
So next time that envelope lands on your table, don’t sigh and shove it in the drawer. Open it, grab a pen, and get to work.
Because yes you can fight a denied prior authorization. And most of the time, you’ll win.
Your turn: Have you ever fought a denial and come out on top? Share your story in the comments. Somebody else out there needs to hear it.