Different denials, different paths.
Surgery, MRI, cancer, medication, Medicare, and prior authorization. Each denial category has its own playbook. Find yours below.
Surgery denials
Surgical denials are issued before the procedure (prior authorization) or after (claim denial). Both have appeal paths. The strategy depends on which.
MRI and imaging denials
MRI, CT, PET, and other imaging denials are almost always issued at the prior-auth stage. They move fast, and so should the appeal.
Cancer treatment denials
Oncology denials are often the most urgent, both medically and financially. Carriers sometimes deny first-line chemotherapy, immunotherapy, off-label uses, and proton therapy. Most reverse on appeal when the oncologist's documentation is filed correctly.
Medication and prescription denials
Drug denials happen at the pharmacy benefit (PBM) layer, separate from the medical benefit. They include non-formulary drugs, GLP-1s, specialty injectables, brand-name vs. generic, and prior-auth-required medications.
Medicare denials
Medicare denials follow a federally-defined 5-level appeal process. Most beneficiaries stop at level 1. The higher levels, particularly the Independent Review Entity and ALJ, reverse a meaningful share of cases.
Prior authorization denials
Most 'denials' people receive are actually prior-authorization refusals, issued before care is delivered. The legal framework, timeline, and leverage are different from post-service claim denials.