Prepare an Appeal

Building a strong appeal significantly increases your chances of overturning an insurance denial. Our experience has shown that well-prepared appeals are much more likely to succeed. 

Step 1: Gather Essential Information 

Begin by collecting all relevant documents related to your case. This creates the foundation for your appeal and ensures you have all the facts necessary to challenge the denial effectively.


Your denial letter is the most important document to review carefully. It should specify exactly why the claim was denied, which provisions of your plan were applied, and what appeal rights you have. Pay close attention to the stated reason for denial, as your appeal must directly address this explanation.

Your insurance policy/plan document (sometimes called the Evidence of Coverage or Summary Plan Description) details your covered benefits and plan limitations. Review it to confirm whether the denied service should be covered under your plan's provisions. Look for specific sections related to your treatment or service.


Relevant medical records provide clinical evidence supporting your need for the denied service. These may include office visit notes, test results, imaging reports, prescription records, and treatment histories. Collect records that demonstrate your condition and why the requested service is appropriate.


Treatment recommendations from your healthcare providers are powerful evidence. Ask your doctor to provide a detailed explanation of why the requested treatment is medically necessary for your specific condition. This should address the insurer's stated reason for denial and explain why alternative treatments would be insufficient.

Step 2: Consult Key Resources

Reaching out to various stakeholders can provide valuable information and support for your appeal:

 

- Your Healthcare Provider: Schedule a conversation with your doctor or their staff about the denial. Ask them to explain why they believe the treatment is necessary and how they would respond to the insurer's reasoning. Request a detailed letter of medical necessity that specifically addresses the insurer's rationale for denial.

- Your Insurer's Customer Service: Contact your insurance company to ensure you fully understand the denial reason. Ask them to clarify any confusing aspects of the denial and inquire about specific information that might strengthen your appeal. Request copies of any internal policies or clinical guidelines they used to evaluate your claim.

- Your Employer's Benefits Department: If you have employer-sponsored insurance, your human resources or benefits manager may be able to help. Employers often have dedicated contacts at insurance companies and can sometimes advocate on your behalf, particularly for self-funded plans where the employer bears the financial risk.

- Patient Advocacy Organizations: Groups focused on specific medical conditions often provide resources for appealing denials related to those conditions. They may offer guidance documents, sample appeal letters, and information about clinical guidelines that support your treatment.

Step 3: Develop a Compelling Case

With your information gathered, focus on building a persuasive argument that directly addresses the insurer's reason for denial:

- Focus on medical necessity by clearly explaining why the treatment is appropriate and necessary for your particular condition. Use your medical history, diagnostic test results, and treatment outcomes to support your case. Emphasize how your specific circumstances warrant the requested care.

- Reference specific plan language that supports coverage for your situation. Quote relevant sections of your policy document that indicate the service should be covered. If the insurer has misinterpreted or misapplied its own policy, point this out explicitly.
- Include supporting studies or guidelines from reputable medical sources that demonstrate the appropriateness of the requested treatment for your condition. These might include clinical practice guidelines from medical specialty societies, peer-reviewed research, or FDA approvals.

Get your doctor to write a detailed letter of support addressing the specific reason for denial. This letter should explain your diagnosis, treatment history, why the requested treatment is appropriate, and why alternatives would be insufficient. It's most effective when it directly rebuts the insurer's stated reason for denial.

Provide a clear chronology of your condition and treatment to date. This helps reviewers understand the context and progression of your care, particularly for complex or long-term conditions.

Step 4: Submit a Complete Appeal Package

Once your case is prepared, assemble and submit your appeal according to your insurer's specific requirements:

 

- Follow your plan's specified procedures exactly as outlined in your denial letter or plan document. Some plans require specific forms, while others accept appeal letters. Note whether the appeal should be submitted by mail, fax, or electronic means.

- Create a professional appeal letter that clearly identifies your name, policy number, claim number, and service date. State explicitly that you're appealing the denial and reference the date of the denial letter. Summarize your argument concisely at the beginning, then provide more detailed supporting information.

- Send all materials via certified mail or with delivery confirmation to document when the appeal was received. This creates a record in case there are disputes about meeting deadlines.

- Keep complete copies of everything you submit, including the appeal letter, supporting documents, and proof of delivery. These may be needed for subsequent levels of appeal.

- Note the submission date and expected response timeframes stated in your plan documents. Mark your calendar for follow-up if you don't receive a response within the required timeframe.

- Consider including a professional cover page and table of contents if your appeal package is substantial. This helps reviewers navigate your materials and ensures nothing is overlooked.

The Office of the Healthcare Advocate can assist with every aspect of this process.

 

Our experienced advocates have helped thousands of Connecticut residents successfully appeal insurance denials and can provide valuable guidance specific to your situation. For personalized assistance, contact us today.

 

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