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.
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
Got a prior auth denial?
Free 24-hour review. Send the denial letter and we'll tell you whether your case has a shot and what the next step would look like.
Start my appealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.