Prior Authorization Denial Appeal

Instructions for Use

This template is for appealing a denial of prior authorization (PA) for medical services, procedures, medications, or equipment. Prior authorization denials can be appealed through the same internal and external review processes as claim denials.

Key Timelines:
- Standard PA Decisions: Currently 30 days; reduced to 7 days starting 2026
- Urgent PA Decisions: 72 hours (24 hours if concurrent care)
- Appeal Filing Deadline: Typically 180 days from denial

New CMS Rule (Effective 2026):
- Insurers must provide specific reason for denial
- Response times shortened significantly
- Electronic prior authorization required

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Prior Authorization Appeal Letter

[Date]

VIA CERTIFIED MAIL, FAX, AND ELECTRONIC PORTAL
[Send via all available methods to ensure timely receipt]

[Insurance Company Name]
[Prior Authorization Appeals Department]
[Street Address]
[City, State, ZIP]
Fax: ______________________________________________

APPEAL OF PRIOR AUTHORIZATION DENIAL
☐ URGENT/EXPEDITED REVIEW REQUESTED

Re: Prior Authorization Appeal

Field	Information
Member Name	______________________________________________
Member ID	______________________________________________
Date of Birth	______________________________________________
Group Number	______________________________________________
Prior Authorization Request Number	______________________________________________
Date of PA Denial	______________________________________________
Service/Medication Denied	______________________________________________
Prescribing/Ordering Provider	______________________________________________
Provider NPI	______________________________________________

Dear Prior Authorization Appeals Department:

I am writing to formally appeal the denial of prior authorization for [SERVICE/TREATMENT/MEDICATION] dated [DATE]. This appeal is submitted pursuant to my rights under the Affordable Care Act, ERISA, and applicable state law.

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Section 1: Authorization Request Details

Service/Treatment Requested

Field	Information
Service/Procedure Name	______________________________________________
CPT/HCPCS Code(s)	______________________________________________
ICD-10 Diagnosis Code(s)	______________________________________________
Quantity/Duration Requested	______________________________________________
Proposed Date of Service	______________________________________________
Facility/Location	______________________________________________
Estimated Cost	$ _____________________________________________

For Medication Requests

Field	Information
Medication Name (Brand)	______________________________________________
Medication Name (Generic)	______________________________________________
NDC Code	______________________________________________
Dosage/Strength	______________________________________________
Quantity	______________________________________________
Days Supply	______________________________________________
Prescribing Physician	______________________________________________
Pharmacy	______________________________________________

For Durable Medical Equipment (DME)

Field	Information
Equipment Description	______________________________________________
HCPCS Code	______________________________________________
Manufacturer/Model	______________________________________________
Purchase or Rental	______________________________________________
DME Supplier	______________________________________________
Supplier NPI	______________________________________________

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Section 2: Denial Information

Reason for Denial (as stated in denial letter)

☐ Not medically necessary
☐ Does not meet clinical criteria
☐ Experimental/investigational
☐ Step therapy required first
☐ Quantity limits exceeded
☐ Formulary exclusion
☐ Prior treatment requirement not met
☐ Not a covered benefit
☐ Out-of-network provider/facility
☐ Incomplete information submitted
☐ Other: ______________________________________________

Denial Reference Number: ______________________________________________

Exact Language from Denial:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Specific Criteria Not Met (if stated):

_______________________________________________________________________________

_______________________________________________________________________________

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Section 3: Urgency Determination

Request for Expedited Review

☐ I REQUEST EXPEDITED/URGENT REVIEW

This request qualifies for expedited review because (check all that apply):

☐ My health could be seriously jeopardized by waiting for standard review
☐ My life is at risk without this treatment
☐ I am in severe pain that cannot be managed otherwise
☐ Standard timing would jeopardize my ability to regain maximum function
☐ My physician has certified medical urgency (attached)
☐ This involves continuation of therapy that is currently being reduced/terminated

Physician Certification of Urgency:

I certify that the standard timeframe for appeal decision could seriously jeopardize this patient's life, health, or ability to regain maximum function.

Field	Information
Physician Name	______________________________________________
Specialty	______________________________________________
NPI	______________________________________________
Phone	______________________________________________
Signature	______________________________________________
Date	______________________________________________

☐ Standard Review Requested (decision within 30 days)

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Section 4: Medical Necessity Argument

Patient's Diagnosis and Condition

Primary Diagnosis:

_______________________________________________________________________________

Relevant Medical History:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Current Symptoms/Functional Limitations:

_______________________________________________________________________________

_______________________________________________________________________________

Why This Treatment is Medically Necessary

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Previous Treatments Tried

Step Therapy/Failed Alternatives:

Treatment/Medication	Dates	Duration	Outcome	Why Failed/Inadequate
__________________	______	________	_______	____________________
__________________	______	________	_______	____________________
__________________	______	________	_______	____________________
__________________	______	________	_______	____________________

Contraindications to Alternative Treatments:

☐ Allergies to alternative medications: ______________________________________________
☐ Drug interactions with current medications: ______________________________________________
☐ Medical conditions preventing alternatives: ______________________________________________
☐ Previous adverse reactions: ______________________________________________

Expected Outcome of Requested Treatment

_______________________________________________________________________________

_______________________________________________________________________________

Consequences of Not Receiving Treatment

_______________________________________________________________________________

_______________________________________________________________________________

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Section 5: Response to Denial Reasons

Addressing Specific Denial Reasons

If denied as "Not Medically Necessary":

_______________________________________________________________________________

_______________________________________________________________________________

If denied for "Not Meeting Criteria":

_______________________________________________________________________________

_______________________________________________________________________________

If "Step Therapy Required":

☐ Step therapy has been completed (documentation attached)
☐ Step therapy should be waived because: ______________________________________________
☐ Patient has contraindication to required steps: ______________________________________________

If "Experimental/Investigational":

☐ Treatment has FDA approval (documentation attached)
☐ Treatment is standard of care (guidelines attached)
☐ Medicare covers this treatment
☐ Clinical trials support efficacy (literature attached)

If "Formulary Exclusion" (medication):

☐ Medical necessity requires brand vs. generic
☐ Formulary alternatives have been tried and failed
☐ Request for formulary exception based on medical necessity

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Section 6: Supporting Clinical Evidence

Clinical Guidelines and Literature

The following support the medical necessity of this treatment:

☐ FDA approval/labeling
☐ Clinical practice guidelines from: ______________________________________________
☐ Peer-reviewed medical literature (attached)
☐ Medicare National Coverage Determination
☐ Medicare Local Coverage Determination
☐ UpToDate or clinical decision support reference
☐ Specialty society recommendations

Specific Citations:

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

Plan's Own Criteria

☐ I believe the treatment DOES meet the plan's stated criteria because:

_______________________________________________________________________________

_______________________________________________________________________________

☐ The plan's criteria are not consistent with accepted medical standards because:

_______________________________________________________________________________

_______________________________________________________________________________

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Section 7: Documentation Submitted

Attached Documents

Medical Records:
☐ Physician's letter of medical necessity
☐ Office visit notes
☐ Treatment records
☐ Test results (labs, imaging)
☐ Specialist consultation notes
☐ Hospital records

Denial Documentation:
☐ Prior authorization denial letter
☐ Explanation of Benefits (if applicable)
☐ Previous correspondence

Clinical Evidence:
☐ Peer-reviewed articles
☐ Clinical guidelines
☐ FDA documentation
☐ Prescribing information/package insert (for medications)

For Step Therapy Override:
☐ Documentation of previous treatments tried
☐ Contraindication documentation
☐ Adverse reaction records

Other:
☐ Prescription (for medications)
☐ Order form
☐ Other: ______________________________________________

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Section 8: Peer-to-Peer Review Request

Physician Peer-to-Peer Review

☐ I request a peer-to-peer review between the ordering/prescribing physician and the plan's medical director or reviewing physician.

Field	Information
Requesting Physician	______________________________________________
Best Contact Number	______________________________________________
Best Times for Call	______________________________________________
Physician's Email	______________________________________________

Many plans require or offer peer-to-peer conversations before finalizing PA denials. This allows the treating physician to discuss the clinical rationale directly with the plan's medical reviewer.

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Section 9: Request for Information

Pursuant to applicable law, I request the following information:

☐ Complete clinical criteria/guidelines used to evaluate this request
☐ Qualifications of the reviewer who denied the authorization
☐ Any internal policies or protocols relied upon
☐ Plan's medical necessity definition
☐ Formulary/coverage criteria (for medications)
☐ Step therapy requirements and alternatives

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Section 10: Demand for Action

I respectfully request that [Insurance Company Name]:

1. Approve the prior authorization for [service/treatment/medication]

2. Expedite review if urgent request criteria are met

3. Arrange peer-to-peer review if requested above

4. Provide written decision within required timeframes:
   - Urgent: 72 hours (24 hours for concurrent care)
   - Standard pre-service: 30 days (7 days effective 2026)

5. If denial is upheld:
   - Provide specific, detailed reasons
   - Explain external review rights
   - Provide instructions for external review

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Section 11: Contact Information

Member:

Field	Information
Name	______________________________________________
Address	______________________________________________
Phone	______________________________________________
Email	______________________________________________

Ordering/Prescribing Physician:

Field	Information
Name	______________________________________________
Practice	______________________________________________
Address	______________________________________________
Phone	______________________________________________
Fax	______________________________________________
NPI	______________________________________________

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Section 12: Certification

I certify that the information in this appeal is true and accurate. I authorize release of medical information necessary to process this appeal.

Member Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

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Physician Attestation

I attest that the requested [service/treatment/medication] is medically necessary for this patient and that the information provided in support of this appeal is accurate.

Physician Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

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Tracking

Field	Information
Date Appeal Submitted	______________________________________________
Submitted Via	☐ Portal ☐ Fax ☐ Mail ☐ Email
Confirmation Number	______________________________________________
Appeal Deadline	______________________________________________
Decision Expected By	______________________________________________
Peer-to-Peer Scheduled	☐ Yes Date/Time: __________________

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If Appeal is Denied

If your prior authorization appeal is denied, you have the right to:

1. Request External Review - Independent third-party review
2. State Insurance Department Complaint - File with state regulator
3. Request State Fair Hearing - For Medicaid/Medicare managed care
4. Legal Consultation - Discuss ERISA or state law remedies

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Resources

• CMS Prior Authorization: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912
• Healthcare.gov Appeals: https://www.healthcare.gov/appeal-insurance-company-decision/
• State Insurance Departments: https://content.naic.org/state-insurance-departments
• CMS 2024 Final Rule (CMS-0057-F): https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

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This template is provided for informational purposes only and does not constitute legal advice. Consult with a healthcare attorney for specific legal guidance.