Your insurer denies a claim for a procedure your doctor says was medically necessary. What is the proper sequence of steps to appeal effectively?

A structured appeals process maximizes your chances of overturning a denial. Start by getting the denial reason and the clinical criteria used in writing — this is your right under ERISA and the ACA. Your physician then submits a letter of medical necessity citing clinical guidelines that support the treatment. If the internal appeal is denied, you are entitled to an independent external review by a neutral third-party reviewer not employed by the insurer. Studies show external reviews overturn insurer denials roughly 40% of the time, and insurers are legally bound by the external reviewer's decision.