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.
The rule that controls this: The plan must disclose the clinical criteria it applied and meet ERISA § 503 decision timelines (72 hours urgent, 30 days standard).
Last reviewed 13 September 2026 · General information, not legal or medical advice · Apellica is not a law firm
What gets denied
- Imaging (MRI, CT, PET)
- Specialty drug prescriptions
- Surgical procedures
- Mental health intensive outpatient or inpatient
- Home health and durable medical equipment
- Out-of-network referrals
Common denial reasons
- Documentation submitted by provider was incomplete
- Plan deems criteria not met (often without disclosing them)
- Step therapy or conservative-care requirements not documented
- Wrong CPT or ICD codes
How we approach the appeal
Mark urgent if the provider can sign off, drops 30-day window to 72 hours. Request peer-to-peer review with the medical director. Force the carrier to disclose the criteria, then have the provider's letter address each criterion.
Urgent: 72 hours. Standard: 30 days. Most plans: 60-180 day filing window.
$500 - $100,000+ depending on care being authorized
- · Denial letter
- · Original prior-auth request
- · Provider's clinical notes
- · Records of any prior conservative therapy
Prior authorization denial? Let's appeal it.
Two-minute micro intake. We confirm fit and reply within one business day with the right path for your situation.
Prior auth denials by insurer
What each plan tends to cite, and the rule that controls it.
- Express Scripts prior auth denials
- UHC prior auth denials
- Aetna prior auth denials
- Cigna prior auth denials
- BCBS prior auth denials
- Humana prior auth denials
- Medicare prior auth denials
- Kaiser prior auth denials
- Ambetter prior auth denials
- Molina prior auth denials
- BCBS FEP prior auth denials
- Caremark prior auth denials
- OptumRx prior auth denials
- TRICARE prior auth denials
- WellCare prior auth denials
This page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.