The appeal letter I wrote when coverage was denied

Dear You,

The denial came on a Tuesday, in an envelope so thin I knew before I opened it. Two pages. The first said no. The second explained, in a font designed to discourage reading, why.

I’m going to walk you through what happened next, because when it happened to me I couldn’t find a single plain-English account of the process. This is one person’s appeal, under one plan, in one state. Yours will differ. But the bones are usually similar, and knowing the bones helps.

What the letter actually said

Once I made myself read it slowly, the letter was more useful than it looked. It contained:

• The specific reason code. Mine was “does not meet plan criteria for coverage,” followed by the criteria, which were written out. That list was gold. It told me exactly what I had to prove.
• The deadline to appeal. For me, 180 days from the date on the letter. Yours might be shorter. Find that number first and write it on the folder.
• The name of the appeal type. First-level internal appeal. There were more levels after it, including an external review by someone not employed by the insurer.
• A phone number and a fax number. Yes, fax. In this decade.

Who I called first

Not the insurer. My prescriber’s office. I asked for whoever handles prior authorizations, and it turned out to be a person named, let’s say, Denise, who had done this several hundred times and spoke about the insurer the way a mechanic speaks about a car model with a known defect.

Denise asked me to send her a photo of the letter. Then she told me what the office would supply: a letter of medical necessity from my prescriber, my relevant history from their records, and documentation that I’d met the criteria the denial listed. She told me what she needed from me: the exact denial reason, the appeal deadline, the member ID, and the fax number. That was it.

Second call was to the insurer, to ask one question: “Can I submit a written statement alongside my prescriber’s appeal?” Yes. So I wrote one.

The letter I wrote, and the timeline

One page. I kept it factual and dull on purpose, because the person reading it is not moved by feelings, they’re checking boxes.

Paragraph one: who I am, member ID, date of the denial, and that I’m requesting a first-level internal appeal.

Paragraph two: the denial reason, quoted exactly, and then a sentence addressing each criterion with a date or a document. “The criteria require X. Enclosed is Y, dated Z.”

Paragraph three: what my prescriber’s office was submitting and the date it was being sent.

Paragraph four: a request for written confirmation that the appeal was received and the date by which I’d hear back.

No story. No pleading. The emotional version of this letter exists, and it’s in my journal, where it belongs.

Day 1: denial received. Day 2: called Denise. Day 5: my statement was done and faxed. Day 9: Denise confirmed the office’s packet went out. Day 11: I called the insurer to confirm receipt and got a reference number, which I wrote on the folder in marker. Day 27: a letter arrived.

Approved. For twelve months, after which the whole dance would need repeating, which I now put on the calendar like a dentist appointment.

If you’re holding the thin envelope

Appeal. Plans deny things as a matter of routine, and a real share of denials get overturned when someone pushes back with paperwork. The office that prescribed your medication has almost certainly done this before. Let them carry the medical part. Your job is the deadline, the folder, and the follow-up calls.

What the medication should be, whether to switch to something covered, what to do while you wait: that is your care team’s conversation, and I’d have it with them the same week the letter arrives, not after the appeal resolves.

Read the letter slowly. Write the deadline down. Call Denise, whatever her name is at your office. It’s dull work, and it’s worth doing.

Want to tell me something? Reply to any Low Volume email, or write to me here. I read everything.

Getting Quiet shares lived experience, general education, and practical tools. For medical decisions and individual treatment questions, talk with your qualified care team.