Which Appeal Letter Do I Need?

Choose the Right Appeal — Without Guessing

If your health insurance claim was denied, choosing the wrong appeal letter can waste time — or cost you the appeal entirely.

Most denials fall into specific categories, even when the denial letter is vague or confusing. This page helps you quickly identify what kind of denial you’re dealing with so you can use the correct appeal template the first time.

Start With This Question

Why did the insurance company say “no”?

Ignore the tone and boilerplate language. Focus on the reason given — even if it’s buried in fine print.

Below are the most common denial types and the appeal letter that fits each one.

1️⃣ Medical Necessity Denial

Common denial language includes:

  • “Not medically necessary”

  • “Does not meet clinical criteria”

  • “Treatment not supported by guidelines”

  • “Level of care not justified”

What this usually means:
The insurer claims the treatment wasn’t necessary — even though your doctor ordered it.

Use this appeal letter: 👉 Medical Necessity Appeal Template

This type of appeal depends heavily on how medical evidence is framed, not just what records you submit.

2️⃣ “Not Covered” / Policy Exclusion Denial

Common denial language includes:

  • “Not a covered benefit”

  • “Excluded under the policy”

  • “Benefit limitation applies”

  • “Service is excluded”

What this usually means:
The insurer is claiming the service is excluded based on policy language — often without clearly explaining where or how the exclusion applies.

These denials are frequently reversible when:

  • The exclusion is vague or ambiguous

  • The insurer applies it too broadly

  • The policy language does not clearly exclude the service

Use this appeal letter: 👉 Not Covered / Policy Exclusion Appeal Template

These appeals succeed when policy language is analyzed and framed correctly, not when people simply argue fairness.

3️⃣ Prior Authorization Denial

Common denial language includes:

  • “Authorization not obtained”

  • “No pre-certification”

  • “Prior approval required”

  • “Authorization denied or expired”

What this usually means:
The insurer claims approval was never granted — even if treatment was urgent or unavoidable.

Use this appeal letter: 👉 Prior Authorization Appeal Template

This is a process-driven denial where timing and wording matter.

4️⃣ Out-of-Network Denial

Common denial language includes:

  • “Out-of-network provider”

  • “No coverage for non-participating provider”

  • “Balance billing”

  • “Higher patient responsibility”

What this usually means:
The insurer is shifting cost to you — even when the situation may qualify for an exception.

Use this appeal letter: 👉 Out-of-Network Appeal Template

These appeals require specific arguments insurers expect but patients rarely use.

5️⃣ Deductible / Patient Responsibility Denial

Common denial codes include:

  • PR-1

  • “Deductible not met”

  • “Patient responsibility”

  • “Cost share applies”

What this usually means:
The insurer says you owe the full amount — sometimes incorrectly.

Use this appeal letter: 👉 Deductible / Patient Responsibility Appeal Template

These appeals often succeed when billing assumptions are challenged correctly.

6️⃣ Diagnosis / Coding Mismatch

Common denial language includes:

  • “Diagnosis inconsistent with procedure”

  • “Invalid code combination”

  • “Procedure not payable for diagnosis”

What this usually means:
The issue may be how the claim was coded, not whether treatment was appropriate.

Use this appeal letter: 👉 Diagnosis / Procedure Mismatch Appeal Template

These appeals are technical — and very easy to mishandle without structure.

Still Unsure?

Some denials involve more than one issue. If your denial letter lists multiple reasons — or none that make sense — start here:

👉 Free AI Prompts for Insurance Appeals

They help you clarify what type of denial you actually have — before choosing a template.

Why This Matters

Insurance appeals are rarely denied because people “said too little.”
They are denied because people used the wrong appeal strategy.

Using the correct appeal letter:

  • Saves time

  • Preserves appeal rights

  • Increases the odds of reversal

Once you identify your denial type, don’t wait.

Most appeals have strict deadlines, sometimes as short as 30–60 days.

👉 Browse Appeal Letter Templates and file the correct appeal before your deadline expires.