---
title: "My Insurance Denied My Claim and I Don't Know Why"
url: "https://denialfacts.com/what-happened"
publisher: "Axion Labs — Denial Facts"
checked: "2026-11-04"
dataset_fixity: "sha256-cda2f9b89c8dde2a74989a35dbe7c0d08ff35dac5456484dc1c03c1b181a67b6"
---

# Your insurance said no and you're not sure why

That is the most common situation there is, not a sign you missed something. The biggest single category in the federal data is denials the insurer never properly explained: 33,793,471 of them. You are not being slow. They were not being clear.

## Figures

| Figure | Value |
| --- | --- |
| Denials the insurer never properly explained | 33,793,471 |
| 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% |

## 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.

## Nothing is lost yet

Take a breath, nothing is lost yet. You almost certainly have 180 days from the date on that letter to appeal, and appealing costs nothing. Whatever else is going on, you probably have months, not days. Check your exact date →

## How to use this page

Get the letter or the Explanation of Benefits in front of you. Work down this list and click the first one that sounds like yours, the wording on your letter will be somewhere in it.

## Find your denial in your own words

| If your letter says this | Then it is this denial | Page |
| --- | --- | --- |
| Does the letter use the words “medically necessary”, “not medically appropriate”, or “criteria not met”? | They say you didn't need the treatment. Your doctor says you did. | https://denialfacts.com/denial-reasons/not-medically-necessary |
| Does it mention “out of network”, “non-participating”, or a provider you did not choose, or was this an emergency? | You got a bill from a doctor you never chose. | https://denialfacts.com/denial-reasons/out-of-network |
| Does it call the treatment “experimental”, “investigational” or “unproven”? | They called your treatment “experimental.” Your specialist recommended it. | https://denialfacts.com/denial-reasons/experimental-investigational |
| Does it say the service is “excluded” or “not a covered benefit” under your plan? | They say your plan simply doesn't cover this. | https://denialfacts.com/denial-reasons/service-excluded |
| Does it mention a missing “referral” or “prior authorization”? | You didn't know you needed a referral first. | https://denialfacts.com/denial-reasons/referral-required |
| Does it say you have reached a “limit”, “maximum”, or used up your visits? | They say you've used up your sessions. You still need them. | https://denialfacts.com/denial-reasons/benefit-limit-reached |
| Does it say you were not eligible, not enrolled, or not covered on the date you were treated? | They say you weren't covered that day. You were. | https://denialfacts.com/denial-reasons/member-not-covered |
| Does it mention missing information, a coding problem, a duplicate, or filing too late? | They denied it over paperwork. Not over your care. | https://denialfacts.com/denial-reasons/administrative |

## If none of them fit

None of them fit, or the letter is vague? Then your denial is in the largest group of all, and the answer is the same for everyone in it: make them tell you the actual reason . You have a legal right to the specific reason and the plan provision behind it, and to a free copy of the file they used to decide. Until they say what they actually decided, there is nothing to argue with, and that request is the single most useful thing you can send.

## What is true no matter which denial you have

A denial is not a final decision. It is the first decision, made quickly, often by someone who never examined you. You get two appeals, and both are free. One inside the insurer, then one to an independent reviewer who does not work for them and whose decision they must accept. The second one is the one nearly everybody skips, 1 in 17,061. Only 1 in 17,061 denials ever reaches independent review, and 22.2% (1,092 of 4,918; interval 22.2-23.8% for counts CMS withheld; 32.6% without SelectHealth) of those that do are overturned. You can hand it to someone else. Your doctor or a family member can file on your behalf with your written permission. You do not have to do this while you are ill.

## What this page is for

If you are here it is because the letter did not explain itself, and that is the normal experience rather than a failure of yours to read it properly. Work down the list, pick the one that sounds closest, and start there, you can change your mind later without losing anything. None of it costs money and none of it needs you to understand insurance. If nothing fits, send us the wording with your name and claim number taken out and we will tell you which one you are looking at. Axion Labs · hello@getaxionlabs.com

## 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/
- 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/

Cite: Axion Labs — Denial Facts, "My Insurance Denied My Claim and I Don't Know Why", https://denialfacts.com/what-happened (checked 2026-11-04). free to quote with the URL.