10 Most Common Insurance Denial Reasons — And How to Fight Each
The 10 most common health insurance denial reasons explained - what each means, why insurers use them, and the specific arguments that win appeals for each type.
Read More →Featured Analysis
Prior Authorization Reform: What the New CMS Rule Means for Your Appeal Rights in 2025
The CMS Interoperability and Prior Authorization Final Rule took effect January 1, 2026, requiring health plans to respond to prior authorization requests within 7 days (standard) and 72 hours (expedited). Here is what changed, what did not, and how to use the new rules in your appeal.
Federal Law
MHPAEA Enforcement Intensifies: How the CAA 2021 Comparative Analysis Requirement Changes Mental Health Appeals
Insurers must now provide comparative analysis showing mental health coverage is not more restrictive than medical coverage. Learn how to request and use this document in your appeal.
News
Cancer Patients Win Major Experimental Treatment Rulings — What Oncology Denials Mean for Appeals
Recent state and federal court decisions have strengthened the right to coverage for treatments listed in NCCN clinical practice guidelines, even when not explicitly covered in plan documents.
Strategy
How to Beat Milliman InterQual: A Patient Guide to Medical Necessity Appeal Evidence
Insurers rely on Milliman and InterQual criteria to deny claims — but the standard is not the law. Learn how to build a countervailing evidence package that peer reviewers must address.
Guide
Step Therapy "Fail First" Policies: How 30+ States Have Restricted These Protocols
More than 30 states now have laws limiting step therapy requirements. If your insurer requires you to "fail first" on cheaper medications, you may be entitled to an immediate exception.
Recent Articles
Jan 2025
No Surprises Act Year 3: How Many Emergency Patients Still Getting Illegally Denied?
Three years after implementation, emergency care denials citing network status or prior authorization requirements continue — despite being illegal. How to fight back and where to report violations.
Dec 2024
Balance Billing After an Emergency: A Step-by-Step Fight Guide
Received a surprise bill from an out-of-network emergency provider? The No Surprises Act protects you — but the process for disputing the bill is specific and time-sensitive.
Dec 2024
ERISA Appeals: Why Your Employer-Sponsored Plan Has Different Rules — and What to Do
Self-funded employer plans are subject to ERISA, not state insurance law. This creates a narrower appeals process — but also specific advantages including the right to sue in federal court.
Nov 2024
GLP-1 Drug Denials: Ozempic, Wegovy, and the New Wave of Weight Loss Medication Appeals
Semaglutide and tirzepatide denials are surging. Learn the formulary exception process, medical necessity documentation requirements, and how to overcome the "lifestyle drug" classification.
Nov 2024
Power Wheelchair Denials on the Rise: What the New LCD Changes Mean for Appeals
CMS Local Coverage Determinations for power mobility devices have changed. Here is what documentation is now required and how the new criteria affect appeal strategies for Medicare beneficiaries.
Oct 2024
Hospital Readmission After Premature Discharge: Using the Data in Your Appeal
If you were discharged prematurely and readmitted within 30 days, that readmission is powerful evidence for a retrospective appeal. Here is how to use CMS readmission data and your records.
Oct 2024
External Review Overturn Rates Hit 40% — Why You Should Always Use This Right
Independent review organizations overturn insurer decisions at a 40-60% rate depending on the claim type. Despite this, fewer than 1 in 100 denied patients ever requests external review.
Sep 2024
Medicaid Managed Care Denials: The Dual-Track Appeal Strategy That Works
Medicaid members can pursue both the managed care organization's internal appeal AND a state fair hearing simultaneously. This dual-track approach dramatically improves outcomes.