NEW YORK, November 1, 2026 – Can you picture yourself sitting around the kitchen table with a mountain of paperwork in front of you, and seeing only one word printed on your medical bill: DENIED. You were prescribed a certain biologic drug by your physician for your aggressive rheumatoid arthritis, but your health insurance provider has ruled it out as being “not medically necessary.”
But you need not despair. The secret that the health care industry does not promote is that a denial is merely the start of negotiations, not the end of the game.
As per the guidelines for patient advocacy from the American College of Rheumatology, less than 1% of insurance denials are ever challenged, even though over half of all appeals end up succeeding.
The first step towards dealing with any rejection is understanding why exactly the claim has been denied. The insurance company must give you a written Explanation of Benefits or a rejection letter that will highlight what policy terms were at stake. It could just have been an administrative mistake with the clinic’s coding or maybe the provider forgot to get prior authorization for the procedure.
Once you know what you are fighting, it is time to gather evidence.
You are required to have a separate folder, either physical or electronic for all forms of correspondence. You are supposed to have the letter of denial, the policy documents, the total medical documentation, as well as the guidelines on treatment procedures. It is important for you to seek from your physician the Letter of Medical Necessity to help justify your condition.
Now that you have gathered all the necessary documents, you should draft an appeal letter. In your letter, write your name, policy number, as well as claim number. Quote your policy that proves your claim along with the notes of your physician.
Submit your package either through the approved portal or by mail, making sure that you adhere to the submission deadlines provided in the appeal process for your plan. In case of emergencies, an expedited review process is available, whereby a decision will be made within 72 hours.
And if your written appeal gets rejected? Don’t panic.
You may request that your physician be involved in a peer-to-peer review, where your physician discusses the necessity of the treatment with the medical reviewer at the insurance company. Should this not help, patients can complain formally to their state’s insurance commissioner or consult a lawyer who deals with health insurance issues.
As you can see from the above example, persistence is sometimes the key to getting your treatment approved. The process of appeal requires time and effort, but it is definitely worthwhile.
