How to fight a health insurance denial, and win.
A denial is the start of a process, not the end. Most appeals that are filed succeed. This guide shows you exactly how to fight back, and how Apellica will build and file the whole appeal for you, with $0 upfront.
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Insurers deny a striking share of claims, and almost no one pushes back. Fewer than 1 in 5 patients appeal a denial, yet a majority of appeals that are filed are decided in the patient's favor. The denial is often the easy part for the insurer to issue and the easy part for you to overturn, if it is done correctly and on time.
How to fight a denial, step by step
1. Read the denial letter and your EOB
Your denial letter and Explanation of Benefits state the exact reason and the denial code. That reason determines everything that follows. A prior-authorization gap, a step-therapy requirement, a formulary exclusion, and a medical-necessity denial each have a different winning path.
2. Find the deadline, and protect it
You generally have 180 days from the denial to file an internal appeal. Urgent requests can be decided in as little as 72 hours. Missing the window is the most common reason a winnable appeal is lost.
3. Get the plan's own coverage criteria
Insurers must disclose the clinical criteria they used. Winning appeals quote those criteria back, point by point, rather than arguing in general terms.
4. Build the medical-necessity case
Document the diagnosis with ICD-10 coding, the treatments already tried and their outcomes, and the clinical rationale. A letter of medical necessity from your prescriber, written to the plan's criteria, is the centerpiece.
5. File the right appeal, then escalate
Submit the internal appeal. If it is upheld, request an independent external review, where someone outside the insurer decides. External reviews overturn a large share of well-documented specialty denials.
Why fighting with AI works
The hard part of an appeal is matching your specific denial to the plan's clinical criteria and the supporting medical evidence, quickly and completely, before the deadline. Apellica's engine drafts that appeal in minutes, mapped to your insurer's own rules, and a human reviewer checks every word before it is filed. You get the rigor of a specialist with the speed of automation, and you never have to navigate the insurer alone.
We fight your insurance, you focus on your health.
$0 upfront. Share your denial in two minutes. We confirm fit and reply within one business day with the right path for your case.
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Frequently asked questions
Is it worth fighting a health insurance denial?
Usually, yes. Fewer than 1 in 5 patients appeal, yet a majority of appeals that are filed are decided in the patient's favor. The barrier is effort and deadlines, not the odds.
How much does it cost to fight a denial with Apellica?
$0 upfront. We assess your denial first and only move forward when there is a real path. You do not pay to find out where you stand.
Can AI really write a health insurance appeal?
AI drafts a faster, more complete first version by matching your denial to the plan's criteria and the medical evidence. At Apellica a human reviewer checks every appeal before it is filed. The result is the rigor of a specialist with the speed of automation.
What denials can Apellica help with?
Prior authorization, step therapy, formulary and tier exceptions, and medical-necessity denials, across GLP-1s, biologics, migraine and asthma therapies, and more. We do not handle cancer or rare-disease cases and will refer you when that applies.
This guide provides general information about the appeal process. It is not legal or medical advice. Apellica is not a law firm. Outcomes depend on documentation, plan terms, and timing.