How to Appeal an Insurance Denial

Upload Your Denial Letter

Take a photo or scan of your denial letter, Explanation of Benefits (EOB), or prior authorization denial. Upload it as a PDF, image, or plain text file. Our system uses AI vision to extract every relevant field: your member ID, claim number, procedure codes, diagnosis codes, the insurer's stated reason for denial, and appeal deadlines.

If you prefer, you can also enter the details manually. Either way, accuracy matters -- the exact denial reason text is the most important piece, because it determines the appeal strategy.

AI Classifies Your Denial

The engine analyzes the denial reason text and classifies it into one of several categories: medical necessity, prior authorization, step therapy or formulary restriction, out-of-network, experimental or investigational, benefit limit, or coding error. Each type requires a fundamentally different appeal strategy.

• Medical necessity denials need clinical evidence proving the treatment is appropriate
• Coding errors need documentation of the correct codes
• Step therapy denials need proof that required prior treatments were tried and failed
• Out-of-network denials may be covered under the No Surprises Act

The classifier also determines whether your plan is governed by ERISA (federal law, for employer-sponsored plans) or state insurance law, which affects your appeal rights and deadlines.

Research: Evidence, Policies, and State Law

This is where ClearCost Appeals does the heavy lifting that would take you hours of research. Three things happen simultaneously:

• PubMed clinical evidence search: The engine searches the National Library of Medicine for systematic reviews, meta-analyses, clinical guidelines, and randomized controlled trials that support the medical necessity of your treatment. Every citation is a real, published article -- we verify each PubMed ID to ensure nothing is fabricated.
• Insurer policy database: We look up your insurer's own published clinical coverage policies. If UnitedHealthcare's own policy says your treatment is covered when certain criteria are met, that is the strongest possible argument. We currently have policies from UnitedHealthcare, Cigna, Aetna, Anthem BCBS, and Humana.
• State rules engine: Every state has different appeal deadlines, external review processes, and consumer protections. The engine checks your state's specific rules, including whether you have access to an independent external review, what the deadline is, and whether your state has a Consumer Assistance Program that can help.

Generate Your Appeal Letter

Using all the research gathered above, the engine generates a comprehensive appeal letter. This is not a generic template. Each appeal is specifically tailored to:

• Your insurer's specific denial reason, quoted back to them
• The relevant clinical evidence, with real PubMed citations
• Your insurer's own coverage policy criteria, showing how you meet them
• Applicable federal and state regulations that support your appeal
• The correct legal framework (ERISA or state law) with proper citations

The engine also generates a draft Letter of Medical Necessity for your doctor. This is a document your physician can review, modify, and sign to accompany your appeal. Having physician support significantly increases appeal success rates.

Submit and Track

You receive specific submission instructions: where to fax or mail your appeal, what supporting documents to include, and critical deadline information. We recommend submitting via both fax and certified mail with return receipt to create a paper trail.

Every appeal is assigned a tracking ID. After you submit and hear back from your insurer, you can report the outcome. This builds our precedent database, which helps calibrate success rate estimates and improve appeal strategies for everyone.

If your internal appeal is denied, you can escalate to an external review (an independent third party reviews your case, and their decision is binding on the insurer) or file a complaint with your state's Department of Insurance.