Insurance Denied My Medication or Procedure? Here's What to Do

A prior authorization, MRI, surgery, or prescription denial is not the final word. Here is why it happens and the exact path to appeal.

By the Fight Back editorial team · Banana Bay Press · Updated July 26, 2026

Don't panic, and don't assume the answer is permanent. Read your denial notice to find the exact reason and deadline. Ask your doctor to request a peer-to-peer review, then file a written internal appeal within 180 days. If your health is at serious risk, request an expedited appeal. If the plan still says no, ask for an independent external review.

Why medications and procedures get denied

Getting a denial for a prescription, an MRI, or a surgery feels personal, but most denials come from a handful of standard rules, not a judgment about whether you deserve care. Understanding which reason applies to you is the first step, because your appeal has to answer the specific objection on your notice.

The most common reasons are:

• Prior authorization denied. Your plan required approval before covering the drug or procedure and decided not to approve the request, often because it wanted more clinical documentation.
• Step therapy ("fail first"). The plan wants you to try a lower-cost drug before it covers the one your doctor prescribed.
• "Not medically necessary." The plan's reviewer decided the treatment isn't needed for your situation based on their coverage criteria.
• Formulary exclusion. The medication isn't on your plan's list of covered drugs.
• Out-of-network. The provider, lab, or facility isn't in your plan's network.

Every one of these can be appealed. Your denial letter (sometimes called an Explanation of Benefits or an adverse determination) is required to tell you the reason and how to appeal. Keep it — you'll build your case around it.

Prior authorization vs. step therapy

These two get confused, but they're different problems with different fixes.

Prior authorization is a yes/no approval step. Your plan generally has to respond to a prior authorization request before you get the service within about 15 days, and within 72 hours for urgent care. If it says no, you appeal by supplying the clinical evidence the plan says is missing — chart notes, test results, and a letter from your doctor explaining why this specific treatment is appropriate for you.

Step therapy isn't really saying the treatment is wrong — it's saying "try the cheaper option first." The fix is a step-therapy exception. Your doctor can request one by documenting that you already tried the required drug and it didn't work, that it's medically inappropriate or unsafe for you, or that delaying the prescribed treatment could harm you. A letter of medical necessity is the centerpiece of both kinds of appeal.

Ask for a peer-to-peer review

Before or alongside a formal written appeal, your prescribing doctor can request a peer-to-peer review — a direct phone call between your doctor and a medical director at the insurance company. Your physician explains, doctor to doctor, why the treatment is medically necessary and why the plan's criteria should be met in your case.

A peer-to-peer can sometimes reverse a denial within days without a lengthy paper appeal, especially when the original denial came down to missing information. Even when it doesn't overturn the decision, it puts your doctor's clinical reasoning on the record and strengthens the written appeal that follows. Ask your doctor's office to request one as soon as you get the denial; there is often a short window to do so.

When to request an EXPEDITED (urgent) appeal

Standard appeals take time — for services you haven't received yet, plans generally must decide an internal appeal within 30 days, and within 60 days for care you already got. When your health can't wait that long, you have a faster track.

Your step-by-step path to appeal

Here's the sequence that gives you the best shot at getting the denial reversed. Move quickly — the clock starts on the date of your denial notice.

1. Read the denial notice carefullyFind the exact reason for the denial, the claim or reference number, and your appeal deadline. Everything else is built to answer that reason.
2. Call your plan and your doctorConfirm what documentation the plan needs and ask your doctor's office to help. Request a peer-to-peer review and, if step therapy is the issue, a step-therapy exception.
3. Gather your evidenceCollect chart notes, test results, prior treatments you've tried, and a letter of medical necessity from your provider tying the treatment to your diagnosis.
4. File the internal appeal in writingSubmit within 180 days of your denial. Include your name, plan ID, claim number, the reason you're appealing, and all supporting records. Send it so you have proof of delivery.
5. Ask for expedited handling if urgentIf a delay could harm your health, request an expedited appeal and have your doctor document why it can't wait.
6. If denied, request an external reviewAfter the plan's final internal denial, request an independent external review — generally within four months. The outside reviewer's decision is binding on your insurer.

For the full walkthrough with what to say at each stage, see our main guide on how to appeal a denied health insurance claim. Denials get overturned all the time — but only for people who file. Persistence, documentation, and deadlines are what win.