Appeal: approved, then denied
Asks your plan to pay a claim for care it approved in advance, and to explain what changed and which plan provision lets it deny payment after approval.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan approved care before you had it and then denied the claim. The federal sources used here do not contain a rule that bars a denial after approval, so this letter rests on the plan's own approval and plan document. Check whether your approval says it is not a guarantee of payment.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: approved, then denied Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] on claim [Claim or reference number], which denied payment for [The care or drug that was denied] ([Date of the care], [Doctor, hospital or pharmacy]) after the plan had approved it. I ask you to reverse that decision and pay the claim as approved under [Name of the health plan], member ID [Member ID].
On [Date the plan approved the care] the plan approved this care. The reference number is [The approval or authorization reference number]. The approval covered: [What the approval covered] Relying on that approval, I received this care: [The care you received, with dates]
The plan later denied the claim for this reason: [The reason the plan gave for the later denial]
I ask the plan to explain what changed between the approval and the denial, to identify the plan provision that allows it to deny payment for care it approved, and to tell me whether any information was missing from the original request. If so, I ask what it was and whether anyone asked me or my provider for it before the care was given.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. Please consider every document and comment I send, including anything that was not before the first reviewer. If the decision rests on a medical judgment, I also ask that you consult a health care professional with training and experience in the relevant field who was not consulted on the first decision.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will pursue every further review available to me, including external review if my case qualifies and a complaint to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter and Explanation of Benefits 2. Copy of the approval letter or portal message 3. My notes of calls with the plan, if I have them 4. The provider's records of the approval, if I have them
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter and Explanation of Benefits
- Copy of the approval letter or portal message
- My notes of calls with the plan, if I have them
- The provider's records of the approval, if I have them
What happens next
- Your plan must decide within 30 days after it receives your appeal if the care has not happened yet, or within 60 days if you have already had it. If your plan has two appeal levels, each level gets half that time. Check the date on your notice, which controls.
- Ask the provider's billing office to hold the bill while you appeal, and ask for their copy of the approval and any notes.
- External review covers decisions that involve medical judgment, so a denial that turns only on paperwork may not qualify. If the plan now says the care was not medically necessary, ask for external review. For most job-based and individual plans you have at least four months after you receive the final denial. Check the date on your notice, which controls.
- You can also complain to the agency that oversees your plan. A complaint does not stop your appeal deadline, so file the appeal first.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Prior authorization denied
Your doctor asked the plan to approve care in advance and the plan said no. The clocks are short, and your doctor can ask for a doctor-to-doctor call. Independent external review is open if the reason is medical and your plan is not grandfathered.
- Denial reason
No prior authorization
The plan says approval was needed before the service and was not obtained. Find out whether approval was really required, who was supposed to ask, and whether getting it was impossible. Your provider often has to act.
- Denial reason
Not medically necessary
The plan says the care is not needed under its own definition. That is a medical judgment, so your doctor's letter carries the appeal. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.