Fewer than 1% of denials get appealed. Be the 1%.

Your insurance denied the claim.
Appeal it — about 1 in 3 appeals win.

Answer 8 quick questions and get the three letters that fight a denial: the internal appeal with the medical-necessity structure insurers must answer, the demand for the exact criteria they used, and the external review request that takes the decision out of their hands. Ready in 2 minutes.

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Letter 1The internal appeal — you have 180 days, and the insurer must answer.

Letter 2The criteria demand — make them show the rule they used.

Letter 3The external review request — an independent decision that binds the insurer.

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Letter 1 — The Internal Appeal

File within 180 days of the denial

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The appeal starts the clock. The criteria demand and external review are what overturn stubborn denials.

Letter 2: demand for the clinical criteria and reviewer credentials they used
Letter 3: external review request — independent and binding on the insurer
Every deadline: 180-day appeal window, 30/60-day insurer clocks, 4-month external review
Urgent-care expedited path (72-hour decisions)
Who regulates your plan: state insurance department vs. federal ERISA route
The physician-letter checklist that wins medical-necessity appeals
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Letter 2 — The Criteria & Records Demand

Send with or right after Letter 1

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Letter 3 — The External Review Request

File within 4 months of the final internal denial

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Your Playbook — Deadlines, Regulators & the Physician Letter

Read before filing

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How to appeal a health insurance denial (and actually win)

Insurers on the federal marketplace denied roughly 19% of in-network claims in recent data — yet fewer than 1% of denials were appealed. Of the appeals that were filed, about a third overturned the denial. The system counts on you giving up. Here's the path:

Internal appeal (within 180 days). A written appeal the insurer is legally required to answer — generally within 30 days for care you haven't received yet, 60 days for care you already got. Urgent cases get expedited handling.
Demand their criteria. Insurers must tell you the specific reason and, on request, the clinical criteria behind a denial. Denials often crumble when someone actually asks for the rule and the reviewer's specialty.
External review (within 4 months of the final denial). An independent review organization decides — and the insurer is bound by the result. Standard decisions in 45 days; urgent ones in 72 hours or less.

Who regulates my insurer?

If you bought your plan yourself or through the marketplace, or your employer's plan is fully insured: your state insurance department takes complaints and runs external review. If your employer self-funds its plan, it's federal ERISA territory — the U.S. Department of Labor (1-866-444-3272). The playbook shows you how to tell which one you have.

What makes appeals win?

A treating physician's letter of medical necessity, the plan's own coverage language, and peer-reviewed support — organized in the structure reviewers expect. That's exactly what these letters scaffold.

Deadline math: denial dated 60 days ago? You still have ~120 days of your 180-day internal appeal window. But evidence gathering takes time — start now.

📧 Questions or trouble with an order? Email customer.service@kitsforthat.com — a real person will help. · Terms, privacy & refunds

Insurance Appeal Letters provides self-help document templates and general information, not legal or medical advice, and is not a law firm, insurance advisor, or patient advocacy service. Appeal rights and deadlines vary by plan type and state and change over time — verify current rules at healthcare.gov or with your state insurance department. Statistics from KFF analysis of 2024 marketplace data.

Your insurance denied the claim.Appeal it — about 1 in 3 appeals win.