Care you receivedEmergency room visitImaging your doctor orderedAnesthesia, in-network hospitalPrescription, as prescribedTherapy visit, continuingDependent's therapy visit$0.00
Reason for denial
Coverage deniedNot medically necessaryPrior authorization not approvedProvider out of networkExperimental or investigationalBenefit limit reachedMember not covered
You have the right to appeal this decision.
DENIED
From: YouTo: the plan, then the reviewer
SAMPLE
Appeal
Re: claim 0042-2291 · notice dated March 2, 2026
I am appealing the denial above. This letter answers the specific reason the notice gives.
Claim file, requested free of charge
The plan's criteria, answered point by point
My clinician's letter
Internal appealby Aug 29, 2026at least 180 days from the notice · 29 CFR 2560.503-1(h)(3)(i)
External review4 monthsfrom the final internal denial · 45 CFR 147.136(d)(2)(i)
The external reviewer's decision binds the plan.
FILED ON TIME
Their clockPre-service appeal: 30 days. Urgent: 72 hours.29 CFR 2560.503-1(i)(2)
Claim file: requestedFree of charge, on request.29 CFR 2560.503-1(h)(2)(iii)
INTERNAL APPEAL DUE
Aug 29
day 180 after a March 2 notice
!Use cases
One letter. Every denial.
In one plan year, insurers denied 84,502,749 in-network claims. Each one arrived as a letter like this. Scroll, and watch it turn from a no into an appeal, one real step at a time.
18.7% of in-network claims denied, 84,502,749 of 451,249,792 (CMS file via denialfacts.com).
Read the letter for the specific reason and the deadline: the notice is required by law to state both. Whether it was a genuine emergency is a clinical question, and medical judgment is exactly what independent external review exists for.
Not medically necessary: 3,968,921 denied claims, 4.6% of all categorized denials. Source · 29 CFR 2560.503-1(g)(1)
2Count their clock too
The prior-auth wait runs on their clock too.
A refusal before treatment is a pre-service claim. The plan must decide your appeal within 30 days, or 15 days per level where it runs two; for urgent care, within 72 hours. If it misses its own deadline, the internal stage can be deemed exhausted.
Rule: 29 CFR 2560.503-1(i)(2). The CMS file counts denied claims, not prior-authorization decisions, so there is no national rate for this one. Source
3Ask for the file
Out of network, from a doctor you never chose.
Was it an emergency, or care at an in-network hospital or surgery center? If either, the No Surprises Act may mean you never owed it. Ask the billing office for the consent form they say you signed, and ask the plan for your claim file. It's free.
Provider out of network: 8,567,575 denied claims, 9.8%. Source · claim file: 29 CFR 2560.503-1(h)(2)(iii)
4Answer their criteria
The medication refused as experimental.
Ask for the medical policy and clinical criteria they applied, then have your prescriber answer them point by point. A denial on the basis that a treatment is experimental or investigational qualifies for independent external review.
California, DMHC-regulated plans only, 2021 onward: 4,373 prescription-drug reviews, 74.8% overturned. Past decisions, not a prediction for any one case. Source
5Show why it must go on
Therapy sessions cut off at the cap.
When the plan says you've used your visits and your clinician says more is needed, that is medical judgment, and it qualifies for external review. Ask for a continued-treatment letter: progress so far, what more treatment should do, the risk of stopping now.
The internal appeal is yours to file; nobody files it for you. Generally 180 days from the notice, so file well inside it. If the letter says the member isn't covered, that's an eligibility denial: usually won by correcting a record, not by winning an argument.
Member not covered: 5,729,108 denied claims, 6.6%. Source · deadline: 29 CFR 2560.503-1(h)(3)(i)
★The second appeal
The appeal is yours. The rule and the date, in your hands.
If the plan upholds its denial, a second window opens: generally 4 months from the final internal denial to ask for independent external review. An organization that does not work for your insurer decides, and the plan is required by law to accept it.
1 in 14,369 denials ever got there. Of the 5,881 that did, 1,929 were overturned: 32.8%. Source · 45 CFR 147.136
Every other no on the list.
Each letter states a reason, and each reason is beaten differently. These are the nine categories insurers reported for 87,173,324 denied claims, in- and out-of-network. Find the words on your letter, then open that page.
Source: denialfacts.com/denial-reasons, from the CMS Transparency in Coverage Public Use File (plan-year 2026 release, plan-year 2024 claims). Bars are scaled to the largest category. A count describes what insurers wrote on their notices, not whether those denials were right.
Free to read. $29 to put it in order.
Everything on this page is published free on denialfacts.com: the rights, the two deadlines, the calculator, the argument for each denial reason. The one paid thing is the Appeal Kit, which dates every step to your own letter.
Free, always
$0
Write the letter, free: four fields and a finished appeal letter on your device, both federal deadlines in it.
Both dates, free: your internal-appeal and external-review dates as calendar dates, with the days remaining.
The document-request letter, complete and unredacted: it asks the plan for its whole case before you write a word.
How to appeal: both stages, what to do tonight, how to ask for expedited handling.
Free help from a person: your state's Consumer Assistance Program, and HealthCare.gov.
The internal appeal is free. External review is free under the HHS-administered federal process; where a state process or a contracted reviewer is used, any fee is capped at $25 per review.
The Appeal Kit
$29one payment
Your two deadlines, worked out from your denial date, with the expedited route explained.
The argument that fits your denial reason.
An evidence checklist: which documents to request from the plan, and what to ask your clinician to write.
A letter of medical necessity brief for your doctor.
The external review request, with what to include so it is not returned.
What happens next, and what to do when the plan misses its own deadlines.
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. If the independent reviewer upholds the denial, send us the decision and we refund. The Kit is assembled in your browser: nothing you type into it is sent to us.
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. A purely administrative denial may not qualify, and we say so rather than sell 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.
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. The letter shown is a sample; its dates illustrate the 180-day count. Every figure here comes from the same data files as the rest of denialfacts.com. Counts: CMS Transparency in Coverage Public Use File (plan-year 2026 release, issued September 26, 2025, plan-year 2024 claims), individual-market plans on the federal Exchange. California figures: DMHC, Independent Medical Review Determinations, Trend, as read by denialfacts.com on September 25, 2026. Rules: 29 CFR 2560.503-1 and 45 CFR 147.136, explained at HealthCare.gov.