Insurance Denial Appeal: How to Fight Back When Your Claim Is Rejected

When your insurance denial appeal, the formal process of challenging a health insurer’s decision to refuse payment for a prescribed medication or treatment. Also known as a drug coverage appeal, it’s not just paperwork—it’s your lifeline to getting the medicine you need. Too many people give up after their first denial, but over 50% of appeals succeed when done right. This isn’t about arguing with a customer service rep. It’s about building a clear, evidence-backed case that shows why the treatment is medically necessary—and why skipping it could cost more in the long run.

Most denials happen because the insurer says the drug isn’t "medically necessary," isn’t on their formulary, or needs prior authorization, a pre-approval step where your doctor must prove the treatment meets specific criteria before coverage is granted. But prior authorization isn’t a roadblock—it’s a checklist. Your doctor’s notes, lab results, and even past treatment failures can be used as proof. If you’ve tried cheaper options first and they didn’t work, that’s not a failure—it’s evidence. Insurers are required to consider this under federal and provincial rules. And if your drug is a generic version of a brand-name drug, they often have to cover it unless they can prove it’s unsafe or ineffective—which they rarely can.

Another common reason for denial? Cost. But here’s the thing: medication adherence, how consistently a patient takes their prescribed drugs. Also known as drug compliance, it’s directly tied to hospital visits and long-term costs. If you skip your meds because you can’t afford them, the system pays more later. That’s why insurers sometimes approve appeals when you show how non-treatment leads to higher expenses—like ER trips for uncontrolled diabetes or heart failure. Your doctor can write a letter showing this chain of risk. You don’t need a lawyer. You need facts, timing, and persistence.

Don’t wait until your prescription runs out. Start the appeal as soon as you get the denial letter. Most plans give you 60 to 180 days to file. Keep copies of every form, email, and phone call. If your doctor’s office won’t help, ask for a patient advocate—they’re often free through your insurer or hospital. And if the first appeal fails, you can request an external review by an independent third party. That’s your final shot, and it’s legally binding.

The posts below walk you through exactly how to do this—step by step. You’ll find real examples of appeals that worked, templates for letters your doctor can sign, how to decode insurer jargon, and what to do when your mental health therapy, hormone treatment, or heart medication gets denied. No fluff. No theory. Just what you need to get your drugs covered.