Prior authorization denied

What it means

Before certain care, your plan wants to approve it in advance. Your doctor sent a request, and the plan refused it. Because the care has not happened yet, this is a “pre-service claim”, and the rules favor speed.

Read the stated reason. It may be that the plan finds the care not medically necessary, that another option must come first, or that information is missing. Each has a different fix.

Who has to act first

Your doctor’s office usually holds the request, so it moves first. It can ask the plan for a peer-to-peer call (a doctor-to-doctor conversation with the plan’s reviewing physician) and send the clinical letter. You can file the appeal yourself. Your appeal deadline counts from when you receive your notice, so do not wait for the office.

Know the clocks:

• Employer plans and Marketplace plans: the plan must decide a first request within 72 hours if it is urgent and 15 days if it is not (one 15-day extension is possible). The plan must decide an appeal within 72 hours if urgent, or 30 days if not (15 days per level if it has two levels). You have at least 180 days after you receive the denial to appeal.
• Medicare Advantage plans: since 1 January 2026 the standard decision is due within 7 calendar days for items and services needing prior authorization, and 72 hours if expedited. To appeal, you generally have 65 calendar days from the date on the denial notice, not 180.

Check the date on your notice, which controls. Medicaid and other coverage differ. If a doctor who knows your condition says the request is urgent, the plan must treat it as urgent.

Arguments that work

• Ask for the specific reason. Since 1 January 2026, Medicare Advantage plans must give the provider a specific reason for a prior authorization denial, and so must insurers on the federal Marketplace, except for drugs. Job-based and other non-grandfathered plans must still state the specific reason in the notice.
• Ask for the criteria. The notice must set out the internal rule or guideline the plan used, or say a copy is free on request.
• Use Medicare’s own limits. A Medicare Advantage plan may use prior authorization only to confirm a diagnosis or medical criteria or to check medical necessity. It must follow Original Medicare’s coverage rules and consider your history and your doctor’s recommendation.
• Point to the plan’s own delay. If a Medicare Advantage plan misses its deadline on your appeal, or upholds its denial, it must send the case to the independent review entity. A job-based plan that fails to follow its own procedures can lose the right to insist that you finish its internal appeal first.
• Ask for a fast external review. In a non-grandfathered private plan, if delay would seriously jeopardize your health, you can ask for expedited external review at the same time as an expedited internal appeal.

Evidence to gather

• The denial notice with the stated reason (you).
• The criteria and the claim file (the plan, free on request).
• Your doctor’s request, clinic notes and a letter on why this care is needed now (your doctor).
• Test results, imaging and records of treatments tried (your provider).

What to send

Send the appeal to the address in the notice by a method that proves delivery: an appeal letter that names the reason, your doctor’s letter, and the records. If the case is urgent, say so in the first line, have your doctor certify it, and appeal by phone or fax as the notice allows.

When this is not worth an appeal

If the notice says information is missing, send the information first. If the notice is a denial, your appeal deadline keeps running, so note it too. For an urgent request the plan must say what is missing within 24 hours and allow at least 48 hours to supply it. For other requests you must have at least 45 days. Supplying what is missing answers the stated reason directly. An appeal that leaves it out does not.