Insurance appeals: a working method

A refusal is a first draft

Petra did eight years in community advocacy before this and holds our insurance-appeals circle, and her opening line has not changed: a refusal letter is a first draft, not a verdict. Refusals are produced at volume, against criteria, often by someone applying a rule to an incomplete file. The overwhelming majority of the ones we see in the circle were not refusals of you. They were refusals of a form that did not contain the thing the rule asked for.

That reframing does practical work. It moves you from "they said no and I am not worth it" to "which box was not ticked", and only the second question has an action attached to it. Members who win appeals are almost never the ones who wrote the most moving letter. They are the ones who found the criterion, answered it in its own language, and attached the evidence in the order the reviewer needed it.

This guide is deliberately unromantic. It is also written to be portable, because the machinery differs by country and the method does not.

Find the criterion you are actually being measured against

Nothing else in this guide works until this is done, and it is the step people skip. Somewhere there is a written rule that your request was assessed against: a formulary policy, a prior-authorisation criteria document, a funding policy, a set of authority requirements, an eligibility standard for a service. It exists in writing and it is usually obtainable.

Ask for it explicitly and in writing: the specific policy or criteria document used to assess this request, by name and version. Insurers and funders are generally obliged to tell you the basis of a decision, and in many systems the criteria are published. Once you have it, read it as a checklist and mark each item as met, not met, or not evidenced. That third category is where most refusals live — the criterion was met and the file did not show it.

Typical criteria in this territory include a documented diagnosis, a measured clinical threshold, documented comorbidities, evidence that specified prior treatments were tried and what happened, evidence of participation in a structured programme, and a prescriber attestation. You are looking for which one you have not evidenced, in their words rather than yours.

Read the letter like a form

Now go back to the refusal itself and extract four things, ignoring the tone entirely.

The stated reason and any reason code. Not the summary sentence — the code or category, which maps to a specific criterion. Refusals commonly cite a general clause when a specific one was the operative test, and asking which specific criterion was not met is a fair and useful question.

The level you are at. Most systems have an internal reconsideration, then an internal appeal, then an external or independent review. Knowing which door you are standing at determines what you send and to whom.

The deadline. Appeal windows are real and unforgiving, and they are the commonest way members lose an appeal they would have won. Put it in a calendar the day the letter arrives.

Who decides next, and whether a clinician can speak to them. Many systems allow a prescriber-to-reviewer conversation — often called a peer review or peer-to-peer — and members report this as one of the highest-yield options available, precisely because it bypasses the form.

Assemble the evidence pack

Build the pack against the criteria list, in the order the criteria appear. A reviewer working through a queue should be able to find each item without hunting.

Usual contents: the diagnosis and when it was made; the relevant clinical measurements with dates, from the record rather than from memory; documented comorbidities, because these frequently carry more weight than the primary indication; a treatment history saying what was tried, for how long, at what dose, and why it was stopped — the "why" line is the one that is nearly always missing; documentation of any structured programme participation, if the criteria ask for it; the prescriber’s statement of medical necessity; and the relevant clinical guideline citation if the criteria reference guidelines.

Two things members underuse. First, contemporaneous notes: a five-line symptom or treatment record from the tracker is genuinely persuasive, because it is dated and specific rather than recalled. Second, the failure narrative: "tried, tolerated poorly, stopped" is far stronger than "did not work", and it is the evidence that answers the "have alternatives been tried" criterion that trips up so many files.

The four paragraphs

Petra’s letter template, unchanged in years because it keeps working. Keep it to one page.

One: what you are asking for and under what mechanism, named precisely — a formulary exception, a reconsideration of a prior-authorisation decision, an individual funding request, an authority application, whichever it is. State the reference number of the original decision and the date. No preamble.

Two: the criterion, quoted from the policy, followed immediately by how you meet it and where the evidence for that sits in the pack. If there are three criteria at issue, three short blocks. Use their vocabulary rather than translating it into yours.

Three: the clinical rationale in the prescriber’s voice, addressing why alternatives are unsuitable — this is the paragraph a medical necessity letter is for, and the prescriber should write it rather than you.

Four: what you are asking the reviewer to do, and by when, with a note that you will escalate to the next level if the decision stands. Polite, procedural, unemotional. Reviewers respond to files that are easy to approve, and the whole letter is an attempt to make approval the path of least effort.

Where you are changes the machinery

The method is portable. The doors are not, and members regularly follow instructions written for somebody else’s country.

United States. Formulary exception and prior-authorisation appeals run through internal reconsideration and internal appeal, then to an external review by an independent organisation whose decision the plan must generally honour. Employer-sponsored plans have their own claims-and-appeals rules with defined timeframes, and expedited review exists where delay would be harmful.

United Kingdom. There is no insurer. Access runs through prescribing criteria, local formulary decisions and specialist weight-management service pathways, with an individual funding request route where a case is argued as exceptional. National guidance from NICE is the document to read and cite.

Ireland. Reimbursement is scheme-based, with applications generally made by a clinician against published criteria rather than appealed by a patient directly.

European Union. Reimbursement is national, not EU-wide, and varies enormously between member states — Noor’s EU circle is where members compare notes on which national mechanism applies.

Canada. Private plans usually run a special-authority or exception process with their own forms; public coverage varies by province.

Australia. PBS listings carry authority requirements, and the question is nearly always whether the authority criteria are met and documented rather than whether an appeal is available.

Keeping the paper trail, and losing well

Log everything: date, who you spoke to, what was said, what was promised, and the reference number. Ask for decisions in writing. Members who kept a log have repeatedly found that the log itself resolved a dispute, because a documented earlier commitment is hard to walk back.

And sometimes you lose. Petra is clear that this is not a failure of your letter or your worth, and that the honest ratio matters more than the story: appeals are won at meaningful rates and they are not won at anything like one hundred per cent. When it stands, there are still moves — a different mechanism, a different indication, a re-application when circumstances change, a clinician-to-reviewer conversation you have not had, a complaint to an ombudsman or regulator where one exists.

There is also the move nobody wants to name, which is stopping because the money is not there. That is a legitimate decision made by a person in a real situation, not a moral event, and paying out of pocket without panic and the paying-out-of-pocket circle are both about doing it without shame attached.