Prior Authorization & Medical Necessity Denials Still Surge — What You Must Include in Your Appeal Letter
Prior authorization was designed to prevent unnecessary care. Instead, it has become one of the most significant barriers to receiving medically necessary treatment, creating delays, financial burdens, and unfair denials for millions of patients every year.
Doctors are speaking out. According to the American Medical Association (AMA), over 60% of physicians report that unregulated AI tools and automated review systems are now denying coverage for medically necessary care—especially in prior authorization workflows. These denials are happening without proper clinical review, without context, and often without legal justification.
For consumers, that means one thing:
You must be prepared to appeal — and your appeal letter must be strong, factual, medically supported, and legally grounded.
This guide explains why prior authorization and medical necessity denials are surging, the most common reasons insurers use, what evidence you need, and how to write a powerful appeal using our FREE Appeal Guide and $29 Health Insurance Appeal Template specifically designed for prior authorization and medical necessity issues.
📈 The Surge in Prior Authorization Denials: What’s Really Happening?
Prior authorization (PA) is the insurance company's requirement that you obtain approval before receiving certain tests, medications, surgeries, or referrals. In theory, it prevents unnecessary or unsafe care. In reality, it has become a cost-control tool that increasingly harms patients.
The AMA reports:
60% of physicians say AI-driven decision tools are denying medically necessary care.
Many prior authorization decisions are made “without regard for clinical nuance.”
Doctors say these systems create dangerous delays in care.
Appeals succeed often — proving many initial denials were wrong.
This confirms what many consumers already experience: These denials are procedural—not medical.
Which means an appeal can absolutely overturn them.
❌ Why Prior Authorization & Medical Necessity Denials Happen
Most denials fall into a few categories — and understanding these helps you build a better appeal.
✔️ 1. “Lack of Medical Necessity”
The insurer claims the treatment is:
Not medically necessary
Not evidence-based
Not standard for your condition
Not justified by documentation
This is one of the most common — and most overturned — denial reasons.
Often, the REAL causes are:
A missing document
A brief or incomplete doctor’s note
Wrong diagnosis code
An automated tool misclassifying your condition
This is where your appeal letter matters most.
✔️ 2. Prior Authorization Was Not Submitted Properly
Insurers may deny your care if:
Your doctor didn’t submit the request
The insurer claims they never received it
The request had missing information
The request used the wrong CPT or ICD-10 code
The request was submitted late
Many of these can be corrected through appeal — especially with supporting evidence from your provider.
✔️ 3. “Lower-Cost Alternative Available”
Insurers often deny a recommended treatment because a cheaper option exists.
Your appeal must include:
Clinical reasons the cheaper option won’t work
Documented treatment failures
Specialist notes
Past medication responses
✔️ 4. Automated Denials Made by AI Tools
This is the growing issue highlighted by AMA.
AI tools often:
Deny requests based on outdated guidelines
Ignore patient history
Use rigid, one-size-fits-all criteria
Apply rules incorrectly
Your appeal should highlight the need for human clinical review.
✔️ 5. Coding Errors
Even one incorrect code (CPT, HCPCS, ICD-10) can trigger:
Prior authorization denial
Medical necessity denial
“Service not covered” errors
Claim payment rejections
Your appeal should ask for reprocessing under corrected codes.
🏥 What You MUST Include in a Prior Authorization or Medical Necessity Appeal Letter
To overturn a prior authorization denial appeal or medical necessity denial appeal, your letter needs to contain specific elements. Missing even one of these can weaken your case.
Below are the required components:
1. Clear Patient & Policy Identifiers
Include:
Name
DOB
Member ID
Claim or authorization reference number
Dates of service
This ensures your appeal is routed correctly.
2. A Precise Statement of Appeal
Example:
“I am writing to formally appeal your denial dated [date] regarding the prior authorization request for [treatment].”
Insurers respond better to clear, direct statements.
3. The Exact Denial Reason (Quoted)
Copy the language from your denial letter:
“Not medically necessary”
“Insufficient information”
“Treatment not covered under plan guidelines”
“Lower-cost alternative required”
“Prior authorization not submitted”
Then directly address it in your appeal.
4. Clinical Evidence Supporting Medical Necessity
This is critical.
Include:
Doctor's letter of medical necessity
Progress notes
Specialist notes
Diagnostic imaging
Lab results
Treatment failure history
ER visit notes
The more evidence you include, the stronger your appeal.
5. Your Provider’s Explanation
Ask your doctor to explain:
Why this treatment is medically necessary
Why alternatives are ineffective or unsafe
Why delays are dangerous
Why you meet criteria under clinical guidelines
Doctors know the exact medical reasoning insurers expect.
6. Legal Grounds Under ERISA or the ACA
If you have an employer-sponsored plan (ERISA):
You are entitled to a full and fair review
Your claim must be reviewed by a qualified specialist
You may request all internal guidelines used
If your denial violated a deadline (very common), cite that too.
7. Request for Reconsideration & Reversal
A strong closing includes:
“Please reconsider and approve this medically necessary treatment based on the evidence, clinical guidelines, and my legal rights to appropriate review.”
⚖️ Why These Appeals Are Often Successful
Most prior authorization or medical necessity denials are not based on legitimate medical reasoning. They are based on:
Automated systems
Missing paperwork
Insurer misunderstandings
Coding issues
Time-saving shortcuts
When you present:
✓ Correct codes
✓ Updated documentation
✓ Doctor’s clinical notes
✓ Evidence of necessity
✓ Supporting medical literature
✓ Clear patient history
…insurance companies often reverse the denial.
📘 Step 1: Download Your FREE Appeal Guide
If you’re overwhelmed or unsure where to begin, start with my Free Appeal Guide.
You’ll learn:
How to read your denial letter
What evidence you need
How to structure your appeal
Internal vs. external review rights
What deadlines apply
How to avoid common mistakes
👉 Download Your FREE Appeal Guide Here
📝 Step 2: Use the $29 Prior Authorization Appeal Template
If you need a strong appeal letter today, use my $29 Appeal Template.
It includes:
Legal-style wording
Sections for prior authorization denials
Medical necessity denial arguments
How to address “lower-cost alternative” claims
Coding-error language
ERISA citations (if applicable)
Fully editable Word format
Fill-in-the-blanks structure for your facts
👉 Get the $29 Prior Authorization / Medical Necessity Appeal Template
This is the fastest and most effective way to fight a prior authorization denial.
Final Thoughts: You CAN Fight a Prior Authorization Denial
Prior authorization and medical necessity denials are increasing — but so is the success rate for appeals.
Insurers deny care because they assume:
Most people won’t appeal
Most people are overwhelmed by the process
Automated systems can deny without pushback
But you can challenge that.
With a strong letter, supporting evidence, and the right arguments, you can overturn a prior authorization denial, prove medical necessity, and get the care you need.
Start by downloading the FREE Appeal Guide, then use the $29 appeal template for a fully structured, ready-to-send appeal letter.
You deserve medically necessary care — and you have the tools to fight for it.
