---
title: "How to Appeal a Health Insurance Denial (2026): Deadlines"
url: "https://denialfacts.com/how-to-appeal"
publisher: "Axion Labs — Denial Facts"
checked: "2026-11-04"
dataset_fixity: "sha256-cda2f9b89c8dde2a74989a35dbe7c0d08ff35dac5456484dc1c03c1b181a67b6"
---

# How to appeal a denied health insurance claim (2026)

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.

## Figures

| Figure | Value |
| --- | --- |
| In-network claims denied | 83,907,852 |
| National denial rate | 15.7% |
| Internal appeals filed | 241,596 |
| External reviews filed | 4,918 |
| Of those, overturned | 22.2% |
| External reviews overturned | 1,092 |

## The free tool on this page

This page carries the deadline tool. Input: the date printed on your denial notice, plus who pays your claims and, if you have it, the reason on the letter. Free result, computed in your browser and never sent anywhere: the calendar date your internal appeal is due (generally 180 days from the notice), the date your independent external review is due after a final internal denial (generally four months), and which body decides your case at the end. Nothing is stored, no address is asked for. The paid thing on this site is the Appeal Kit, $29, at https://denialfacts.com/appeal-kit , and it sequences every step around those two dates. Everything the Kit relies on is published free here, and the two dates are free with or without it.

## 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 to do first, and tonight

“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. What to do tonight 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.

## What those two overturn rates mean for one denial

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.

## Which denials qualify for external review

Which denials qualify for external review. Not every denial does. External review covers denials that involve medical judgment , denials on the basis that a treatment is experimental or investigational , and rescission of coverage. A purely administrative or eligibility denial may not qualify for external review, but it is still fully appealable internally, and administrative denials are often the easiest to reverse there.

## 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. Who these figures describe. California only, and only health plans regulated by the DMHC. They do not cover self-funded employer plans, which fall under the federal ERISA law and not the DMHC, and they do not cover plans in any other state. They are past decisions, not a prediction for any one case: a rate here is the share of decisions reviewers overturned, and a single case turns on its own records and the plan's own criteria.

## California decisions by type of treatment

| 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% |

## California decisions by kind of case, and the source

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.

## A card for a forum reply

A card for a forum reply: 176,949 internal appeals not overturned, 4,918 external reviews filed. 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, https://denialfacts.com/external-review-gap .

```text
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
```

## The gap this site exists for

The gap this site exists for: 83,907,852 denials, 4,918 external reviews. One in 17,061. Of those who go, 22.2% win, and the insurer has to comply.

## A live federal deadline

Notice for Alabama, Florida, Georgia, Texas, Wisconsin and the territories other than Puerto Rico, there is a deadline in this one. CMS says the HHS-Administered Federal External Review Process reopened on July 31, 2026. If your plan uses that process and you could not file between July 1, 2026 and August 3, 2026, CMS says you may be eligible for an extension and have until October 2, 2026 to request external review. If you filed before July 1, 2026 you do not need to resubmit; if you already have a final decision through the federal process, the extension does not apply to you. HealthCare.gov names one group this state-by-state page cannot show you: it says the extension may reach you if you have a state or local government plan in any state , not only in the states whose insurers use the federal process. Both pages were read at source on September 5, 2026 and this is what they said that day, the CCIIO external appeals page and HealthCare.gov on external review . Read them again before you rely on this: it is a live deadline and it has moved once already. Keep evidence of when you tried to file.

## What makes an appeal work

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

The peer-to-peer call is not your appeal If your doctor is booked in for a peer-to-peer, your 180 days are still running. A peer-to-peer is a phone call between your doctor and a doctor working for the insurer. It is the insurer's own process, not a step in the federal appeal system: it does not start your appeal, it does not stop your deadline, and it is not the “full and fair review” the rule requires. File the internal appeal on your date anyway, and treat the call as something that can only help. 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.

## What readers say about the peer-to-peer

| What they said | Where | Posted | What it tells you |
| --- | --- | --- | --- |
| Only my doctor’s office can request a peer-to-peer with my insurance company. | YouTube | March 17, 2026 | Usually true. |
| Ours too, and we were told it could only happen if the appeal failed. | YouTube | 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. | YouTube | 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. | YouTube | October 17, 2023 | Sometimes it happens twice and changes nothing. |
| It was my first peer-to-peer. I did not realize that that simply does not occur. | ProPublica | February 2, 2023 | A treating physician, describing his own first one to |

## Where the deadline actually comes from

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 .

## What a reader said

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. We hear this most. r/backpain, “Insurance denied MRI. Now what?” , read September 3, 2026.

## The pages that answer the next question

The pages that answer the next question If your employer pays the claims itself , then your insurer is only administering the plan, your state's external review has no power over the denial, and the route is federal. It is the first question our own calculator asks. Before you pay a lawyer , two free appeals run before anyone bills you by the hour, and your insurer has to hand you the claim file for nothing under 29 CFR 2560.503-1. If it was refused before the treatment , a prior-authorization refusal from your insurer runs on the same two federal clocks as a denied claim, and it can be appealed while the treatment is still ahead of you. Denial code CO-50 on the remittance , "not deemed a medical necessity" is the single most common category in the federal file, and it is the one your insurer has to show you the written criteria for. Write the letter, free, and dated from your notice , the internal appeal this page describes, rendered as a finished letter on your device with both deadlines in it. The full deadline calculator , both federal dates as calendar dates with the days remaining, and which body decides your case at the end. All 29 states , the consumer telephone number for your own insurance department, read at source, and your external-review route.

## Who wrote this, and when

By Axion Labs · August 19, 2026, updated November 4, 2026

## The two federal clocks

The clock your letter has to describe, in actual dates Whatever else is on the page, these two dates are the page. 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.

## How rare the second appeal is

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.

## What is free here, and what the one paid thing costs

Denied a claim? Insurers upheld 165,863 of the 262,982 internal appeals counted in 2024, 63.1% ( KFF ). The win is at independent external review, and the only way to arrive there is to run the internal stage on time, in the right order, with the record intact. That sequence is what the Appeal Kit is. Get my Appeal Kit, $29 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. Get my Appeal Kit, $29 Everything 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.

## What we will not pretend

What we will not pretend. We cannot overturn your denial. Only your plan, or an independent reviewer, can do that. We cannot make your plan cover a service it genuinely excludes. We cannot guarantee external review applies to your denial. It covers medical judgment, experimental or investigational determinations, and rescission, a purely administrative denial may not qualify, and we say so on those pages rather than selling you past it. We have no customer testimonials and publish none. Our evidence is the federal dataset and the regulation cites, both of which you can check.

## Every page on this site

Home Start here Insurers By company States Denial reasons Use cases How to appeal Ranked by denial rate The external-review gap Write the letter, free Deadline calculator Self-funded plan? Prior authorization denied Medicare WISeR denial Denial code CO-50 Before you call a lawyer Attorney for a denied claim Your denial letter United Healthcare denying claims Time limits on a claim Appeal a Medicare denial About Editorial policy How we compare Privacy Terms For machines: llms.txt openapi.json changes.json the composed answer this page as markdown

## Which release these figures are

Which release these figures are 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. 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.

## Where these numbers come from

Where these numbers come from 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) .

## Who publishes this

Denial Facts publishes federal data about health insurance claim denials. We are independent: not affiliated with, endorsed by, or acting for any insurer, government agency, or review organization. We are not a law firm, a medical provider, or an insurance producer, and nothing here is legal, medical, or insurance advice. Data: CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain. Figures cover individual-market Qualified Health Plans on the federal Exchange and come from the plan-year 2027 release, 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. See where the data comes from .

## Not advice

This page presents federal statistics and a general description of appeal rights created by federal law. It is not legal, medical, or insurance advice, and no outcome is guaranteed. Your denial letter and plan documents govern your specific case. Free help is available from your state's Consumer Assistance Program and from the federal Marketplace at HealthCare.gov.

## Sources

- CMS Transparency in Coverage Public Use File (PY2027 release, PY2025 claims), data.healthcare.gov — US Government public domain: https://data.healthcare.gov/
- CCIIO state external review table (read August 3, 2026): https://www.cms.gov/CCIIO/Resources/Files/external_appeals
- 29 CFR 2560.503-1 (180 days, and your free right to the claim file): https://www.ecfr.gov/current/title-29/section-2560.503-1
- 45 CFR 147.136 (4 months, and what qualifies): https://www.ecfr.gov/current/title-45/section-147.136
- HealthCare.gov on external review: https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
- DMHC, Independent Medical Review (IMR) Determinations, Trend, California Health and Human Services Open Data Portal (read September 25, 2026): https://data.chhs.ca.gov/dataset/independent-medical-review-imr-determinations-trend
- DMHC IMR data dictionary (read September 25, 2026): https://data.chhs.ca.gov/dataset/b79b3447-4c10-4ae6-84e2-1076f83bb24e/resource/2c5c2144-138f-4feb-b2af-a1176995e1b1/download/imrdatadictionary.pdf

Cite: Axion Labs — Denial Facts, "How to Appeal a Health Insurance Denial (2026): Deadlines", https://denialfacts.com/how-to-appeal (checked 2026-11-04). free to quote with the URL.