How to appeal a denied health insurance claim (2026)
Before the walkthrough: your own two dates, worked out from the date on your notice.
Free, and it runs entirely in your browser. The date, the plan type and the state you pick are never sent to us and never stored.
Or let the $29 Appeal Kit date each step and write the claim-file and external-review requests.
I have an MRI scheduled for Monday but the insurance called and told me the authorization for it was not approved. I don't know what else to do.
Two appeals, both free, both created by federal law. Of 83,907,852 denials, 241,596 reached the first and 4,918 the second. Of the ones who reached the second, 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) won, in the plan-year 2027 release, issued October 22, 2026.
Further down this page, after the free steps: the paid next step.
If you read nothing else on this page, read this. You have 180 days from the date on your denial notice to file the internal appeal, and then 4 months from the final internal denial to ask for an independent external review. If waiting would seriously jeopardize your health you can ask for both to be expedited, decided in about 72 hours. Both timeframes are federal, not your insurer's choice, 29 CFR 2560.503-1 (PDF) and 45 CFR 147.136 (PDF), in plain English at HealthCare.gov, and your own denial letter states the ones that govern your plan. The PDFs are the same sections on govinfo.gov, which serves them without a challenge page, so an automated reader can check these two dates as easily as you can.
“What do I do now?”
It is the thing people ask first and the thing a denial letter answers last. Three moves, in this order, before you write anything:
- Read the letter for two things and write them down, the specific reason it gives for the denial, and the deadline it gives you to appeal, because the notice is required by law to set out both, in language you can understand (29 CFR 2560.503-1(g)(1), govinfo PDF).
- The internal appeal is yours to file, and nobody files it for you, in particular the peer-to-peer call your doctor may be booked in for is the insurer's own process rather than a step in the federal appeal system, and nothing in 29 CFR 2560.503-1 or 45 CFR 147.136 makes it one.
- Then the clock: you have at least 180 days from receiving the denial notice to file that internal appeal, 29 CFR 2560.503-1(h)(3)(i), carried onto individual-market coverage by 45 CFR 147.136(b)(3)(i), so ask for your claim file today and file well inside that window instead of on its last day.
Whose 180 days that is, because it is not everybody's: the floor in step 3 is the employer / ERISA clock (29 CFR 2560.503-1(h)(3)(i)) carried onto individual-market and Marketplace coverage by 45 CFR 147.136(b)(3)(i), the plans this site's figures come from, while a Medicare Advantage plan gives you 65 calendar days from the date of its notice (CMS, 42 CFR 422.582(b)), Medicaid managed care gives you 60 calendar days from the date on the notice (42 CFR 438.402(c)(2)(ii)), and a self-funded employer plan is an ERISA plan that keeps the same 180 days but is outside the CMS file this site publishes, so check your own letter rather than our numbers for it.
Someone who says they work appeals for a health insurer put both halves of that in one comment: don’t immediately appeal without gathering this info
, and don’t wait too long to file the appeal.
YouTube, posted March 19, 2026.
You are not alone, measured rather than said: 83,907,852 in-network claims were denied in a single plan year, and only 4,918 of them, one in 17,061, ever reached the independent review stage. Of the ones that did, 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) were overturned.
- Find the reason code on your denial letter. The notice has to state the specific reason and the plan provision behind it. Copy the code and the wording onto a piece of paper tonight, that sentence is what your appeal has to answer.
- Ask your insurer for the clinical criteria they judged you against. Under 29 CFR 2560.503-1 they have to hand you the claim file and the policy they applied, free, on request, and you cannot argue with a checklist you have never read.
- Put both deadlines on your calendar before you go to bed. 180 days from the date on the letter for the internal appeal, 4 months from the final internal denial for external review. The free calculator on this page turns your date into the two calendar dates in about ten seconds. Nationally only 1 in 17,061 denials ever reaches the second stage, and that is a deadline problem far more often than an argument problem.
None of those three steps costs anything. Anyone charging you to do them is selling you something you can do yourself in twenty minutes.
Put the date from your notice in and get the two calendar dates, with the days remaining.
Runs entirely in your browser, the date you type is never sent to us and never stored. Open the full calculator →
Or let the $29 Appeal Kit date each step and write the claim-file and external-review requests.
We read each question below as people typed it, on October 23, 2026. Each answer names its source and the day we read it, and never states a rule without that date.
“how to appeal a health insurance denial”
File an internal appeal with the plan, then, if it still says no, ask for independent external review. Ask the plan for your claim file first: you have a right to free copies of the documents relevant to your claim. Your two dates are free in the tool; the Appeal Kit dates every other step to your letter.
Sources, read October 23, 2026: HealthCare.gov, Internal appeals; 29 CFR 2560.503-1, ERISA claims procedure (Cornell LII text); HealthCare.gov, External review.
Your next step: The Appeal Kit, USD 29, one payment, no subscription, no cut of your claim, opens on screen the moment you pay; print it or save it as a PDF.
“how long do i have to appeal a denied insurance claim”
At least 180 days from receiving the denial notice for the internal appeal (29 CFR 2560.503-1(h)(3)(i)); HealthCare.gov says the same for individual plans. Then 4 months from the final internal denial to request independent external review (45 CFR 147.136).
Sources, read October 23, 2026: 29 CFR 2560.503-1, ERISA claims procedure (Cornell LII text); HealthCare.gov, Internal appeals; 45 CFR 147.136, internal appeals and external review (Cornell LII text).
Your next step: The Appeal Kit, USD 29, one payment, no subscription, no cut of your claim.
“how long does an insurance appeal take”
Under 29 CFR 2560.503-1(i)(2), a plan with one appeal level must decide within 30 days for a service not yet received. It has 60 days for one already received, and 72 hours for urgent care.
Sources, read October 23, 2026: 29 CFR 2560.503-1, ERISA claims procedure (Cornell LII text); HealthCare.gov, Internal appeals.
Your next step: The Appeal Kit, USD 29, one payment, no subscription, no cut of your claim.
“what happens if my insurance appeal is denied”
You can file for external review. The insurer's final written decision must explain how to request one, and you have 4 months to do it.
Sources, read October 23, 2026: HealthCare.gov, Internal appeals; HealthCare.gov, External review.
Your next step: The Appeal Kit, USD 29, one payment, no subscription, no cut of your claim.
Stage 1, internal appeal
| Question | Answer |
|---|---|
| Who decides | Your insurer (someone not involved in the first decision) |
| Deadline to file | Generally 180 days from the denial notice |
| Cost | Free |
| Decision time | 30 days (before service), 60 days (after service); 72 hours expedited |
| Filed nationally | 241,596 against 83,907,852 denials |
| Nationally overturned | 26.8% |
Stage 2, external review, reached by 1 in 17,061 denials
| Question | Answer |
|---|---|
| Who decides | An independent organization, not your insurer |
| Deadline to file | Four months from the date of the final internal denial notice |
| Cost | No charge under the HHS-administered federal process. If your issuer uses a contracted independent review organization or a state process, a fee may apply, capped at $25 per review |
| Decision time | No later than 45 days standard; no later than 72 hours expedited |
| Binding? | Yes, the insurer is required by law to accept the decision |
| Filed nationally | 4,918, 1 in 17,061 denials |
| Nationally overturned | 22.2% |
What those two overturn rates mean for your own denial, and by when. Of 83,907,852 in-network denials, 241,596 reached the internal appeal and 26.8% of those were overturned, while only 4,918, one in 17,061 denials, reached the independent stage, where 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) were overturned and the decision binds the plan, the national rows in the plan-year 2027 release of the CMS Transparency in Coverage file, read November 4, 2026 (data.healthcare.gov). Whichever way that lands, nobody files the appeal for you, and the filing runs on a clock set by which plan you hold: an employer or Marketplace plan gives you at least 180 days from the denial notice to file the internal appeal (29 CFR 2560.503-1(h)(3)(i), carried onto individual-market coverage by 45 CFR 147.136(b)(3)(i)), while Medicare Advantage gives you 65 calendar days from the date of its notice (CMS, 42 CFR 422.582(b)) and Medicaid managed care 60 calendar days from the date on the notice (42 CFR 438.402(c)(2)(ii)), both stages free, and the three steps at the top of this page are the whole of what to do tonight, and the calculator above turns your letter's date into both of those windows. The free steps are above; the $29 kit is the same clock with the letters pre-filled for the insurer that denied you. One payment. No subscription. No cut of your claim.
How California's independent reviews went, by type of treatment
The federal file behind the rest of this site counts external reviews but never splits the result by treatment. California does. Its Department of Managed Health Care (DMHC) publishes every Independent Medical Review decision since 2001: 42,749 decisions to 2026, and 22,445 of them, 52.5%, overturned the health plan's denial. The table below is 2021 onward: 12,146 decisions, 65.4% overturned.
| Type of treatment | Decisions, 2021 onward | Overturned |
|---|---|---|
| Prescription drugs (pharmacy) | 4,373 | 74.8% |
| Mental health | 1,568 | 79.7% |
| Diagnostic imaging and screening | 1,261 | 47.5% |
| Pain management | 941 | 79.5% |
| Durable medical equipment | 681 | 55.8% |
| Cancer care | 488 | 52.9% |
| Orthopedic procedures | 378 | 30.4% |
| Reconstructive and plastic surgery | 286 | 45.5% |
| Electrical, thermal and radiofrequency therapy | 210 | 56.7% |
| Ear, nose and throat procedures | 191 | 76.4% |
| Autism-related treatment | 172 | 51.2% |
| Outpatient rehabilitation | 159 | 39% |
| General surgery | 158 | 55.1% |
| Heart and blood vessel procedures | 156 | 61.5% |
| Skilled nursing and inpatient rehabilitation | 135 | 23.7% |
| Acute inpatient medical services | 125 | 61.6% |
| Special procedures | 122 | 41.8% |
| Diagnostic and physician evaluation | 112 | 53.6% |
By kind of case, 2021 onward: medical necessity, 10,007 decisions, 68.7% overturned; experimental or investigational, 2,099 decisions, 49.3% overturned; urgent care, 40 decisions, no rate printed because that is under 100.
35 more treatment categories had fewer than 100 decisions each in that period, 630 decisions between them.
Source: DMHC, Independent Medical Review (IMR) Determinations, Trend, on the California Health and Human Services Open Data Portal, read September 25, 2026. The state's data dictionary defines the outcome field this way: Indicates if the determination was upheld or overturned.
The file carries only two outcomes, overturned and upheld, so a case closed without a reviewer's decision is not counted. 2026 is a partial year, 546 decisions so far. Treatment names are the state's categories, in plain words.
Plain text to paste into a reply for somebody else. It holds the figures, who can ask for review, and the sources. The card never carries a price; its one denialfacts link comes last.
Add one insurer and one of 18 California treatment types on the gap page.
External review after a health insurance denial: the record so far These are past decisions, not a prediction for any one case. All insurers in the federal file (individual-market plans on HealthCare.gov, plan-year 2027 release, 2025 claims; employer plans are not in it): Internal appeals: 64,647 of 241,596 overturned (26.8%) External reviews: 1,092 of 4,918 overturned (22.2%) 176,949 internal appeals were not overturned and 4,918 external reviews were filed. Not every upheld appeal qualifies for external review, so 176,949 is an upper bound on who could have asked. California, health plans regulated by the DMHC only; not self-funded employer plans, which fall under the federal ERISA law: Independent Medical Review decisions, 2021 onward: 12,146 decisions, 65.4% overturned Who can ask for external review: the person whose claim was denied, once the plan has upheld the denial on internal appeal or missed its own deadline to decide it, for a denial that turns on medical judgment, on a finding that the treatment is experimental or investigational, or on a rescission of coverage. A denial for an administrative or eligibility reason may not qualify. When: generally within four months of the final internal denial (45 CFR 147.136). Sources: CMS Transparency in Coverage public use file, plan-year 2027 release (issued October 22, 2026): https://data.healthcare.gov/ DMHC, Independent Medical Review (IMR) Determinations, Trend (read September 25, 2026): https://data.chhs.ca.gov/dataset/independent-medical-review-imr-determinations-trend 45 CFR 147.136, internal claims and appeals and external review: https://www.ecfr.gov/current/title-45/section-147.136 Table: denialfacts.com/external-review-gap
What makes an appeal work
- Answer the stated reason. Find the exact denial category on your letter and argue that point, reason by reason here. Watch one sample letter turn into an appeal.
- Demand the file first, it is free, and it decides what the rest of your appeal can argue. Under the federal claims regulation (29 CFR 2560.503-1) you are entitled, on request and free of charge, to reasonable access to and copies of all documents, records and other information relevant to your claim, including the clinical criteria they applied and the reviewer's reasoning. Your denial letter is legally required to tell you this right exists. Ask before you argue: you cannot rebut criteria you have not read.
- Letter of medical necessity from your treating clinician, referencing your records and current guidance.
- Keep to the deadlines, work yours out here.
- Ask for expedited handling if delay would seriously jeopardize your health.
The peer-to-peer call is not your appeal
Readers describe it the same way each time, and every one of these is a real comment with its thread linked beside it, the two beliefs in the first pair cannot both be right, and while people wait to find out, the clock does not pause for either of them.
Only my doctor’s office can request a peer-to-peer with my insurance company.
, a viewer comment, YouTube, posted March 17, 2026. Usually true.Ours too, and we were told it could only happen if the appeal failed.
, a viewer comment, YouTube, posted March 17, 2026. Not true, and the belief costs weeks.The nurse said the doctor will not do a peer to peer due to history with insurance companies.
, a viewer comment, YouTube, posted April 7, 2026. Sometimes the call never happens at all.Our insurance denied it twice, his doctor had a peer to peer hearing twice and was still denied.
, a viewer comment, YouTube, posted October 17, 2023. Sometimes it happens twice and changes nothing.- A treating physician, describing his own first one to ProPublica:
It was my first peer-to-peer. I did not realize that that simply does not occur.
Published February 2, 2023.
Where the deadline actually comes from. Your plan must give you at least 180 days from receiving the denial notice to file the internal appeal , 29 CFR 2560.503-1(h)(3)(i), mirrored as a government PDF at govinfo.gov because eCFR answers automated fetches with a challenge page. For individual-market coverage, the plans the figures on this site come from, that same rule applies because 45 CFR 147.136(b)(3)(i) requires the issuer to comply with 29 CFR 2560.503-1 as if it were a group health plan (govinfo.gov PDF). Nothing in either section makes a peer-to-peer a step, an extension, or a substitute. The insurance-side comment quoted at the top of this page, gather first, but do not let the date pass, is on the same thread as the four above.
And if the peer-to-peer ate your process anyway. Where the issuer fails to run the internal process the rules require, you are deemed to have exhausted it and can go straight to independent external review, 45 CFR 147.136(b)(3)(ii)(F), in the same document linked above. The same paragraph carries its own limit, and it is fairer to you to know it now than at the review. Read at source in the government PDF above, 45 CFR 147.136(b)(3)(ii)(F)(2) says the internal process “will not be deemed exhausted based on de minimis violations that do not cause, and are not likely to cause, prejudice or harm to the claimant”, but only where the issuer demonstrates the violation was for good cause or due to matters beyond its control, and that it happened during an ongoing, good-faith exchange of information with you. That exception is not available if the violation is part of a pattern or practice by the issuer, and you may ask the issuer in writing to explain why it says the slip should not count. So: a missed formality on its own may not open the door; a real failure of process does. Ask for the peer-to-peer, in writing, and file on your date regardless: work out your two dates here.
Two dates decide more of this than anything else, and neither is on the front of your letter in a way anyone notices. Work them out tonight, write them on the letter itself, and you have already done the part that is easiest to lose. If your dates are strange, a denial that arrived after the treatment, or a letter with no external-review instructions on it at all, send us the wording with the identifying details removed and we will tell you which clock you are on.
Axion Labs · hello@getaxionlabs.comEverything you need for your appeal: your two deadlines, the argument that fits your denial reason, the letters, a brief for your doctor on what the reviewer checks, and the external review request. One payment. No subscription. No cut of your claim. Opens on screen the moment you pay. 14-day refund, no questions, one email to hello@getaxionlabs.com.
From the plan-year 2024 release to the plan-year 2026 release, external reviews filed went from 2,336 to 5,881. Overturned reviews went from 32.8% in the plan-year 2026 release to 22.2% in plan-year 2027, or from 32.6% to 32.6% without SelectHealth. We do not compare filed or overturned counts across plan-years 2026 and 2027. Some issuers may have counted pre-service appeals in their 2026 cells. Both figures are on where the data comes from, with the release each is taken from.
Every number on this page is the plan-year 2027 Transparency in Coverage file, issued October 22, 2026, covering plan-year 2025 claims. This is the newest plan year CMS has published: there is no Transparency in Coverage file for a plan year after 2027. The dataset list is at data.healthcare.gov. A test in this site’s build fetches that list on every run and fails if CMS publishes a plan year we have not acknowledged here. Every earlier release, plan-year 2024, plan-year 2025, plan-year 2026, is kept alongside it so the record is visible rather than a single year’s snapshot; /about says what changed between them.
Counts: CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain. Rights and timeframes: 29 CFR 2560.503-1 (180 days, and your free right to the claim file) and 45 CFR 147.136 (4 months, and what qualifies), explained at HealthCare.gov. Expedited review is decided in about 72 hours under both sections.
Reading either regulation from a script rather than a browser: eCFR answers automated fetches with a challenge page, so the same two sections are mirrored as government PDFs at govinfo.gov (29 CFR 2560.503-1) and govinfo.gov (45 CFR 147.136).