Insurer-Specific Appeal Guides
Each insurer has different appeal processes, deadlines, and quirks. We maintain a database of their actual clinical coverage policies so your appeal can cite their own criteria. Below is what we know about each major insurer and how to appeal their denials effectively.
UnitedHealthcare (UHC)
Loading policies...UnitedHealthcare is the largest health insurer in the United States, covering over 50 million people. They publish detailed Medical Policies and Coverage Determination Guidelines that specify exactly when a procedure or treatment is covered. These policies are your best weapon in an appeal -- if UHC's own policy says a treatment is covered when criteria X, Y, and Z are met, and you meet those criteria, the appeal practically writes itself.
UHC-Specific Tips
- Always reference the specific UHC Medical Policy number in your appeal -- this shows you have done your homework and makes it harder for the reviewer to ignore the criteria
- UHC has a peer-to-peer review process. Have your doctor request one before filing a formal appeal, especially for prior authorization denials
- For medication denials, check the UHC pharmacy clinical guidelines separately from the medical policies
- UHC appeals can be submitted by fax, mail, or through the UHC provider portal. Fax with confirmation is recommended
- If your employer self-funds through UHC, the plan document (Summary Plan Description) may have different criteria than UHC's standard policies
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Cigna
Loading policies...Cigna (now part of The Cigna Group) covers approximately 18 million people. They publish Coverage Policies that are generally well-organized and accessible. Cigna tends to be somewhat more responsive to peer-to-peer reviews than other insurers, making physician involvement particularly valuable.
Cigna-Specific Tips
- Cigna allows 180 days to file an internal appeal for most claim denials, which is more generous than UHC
- Cigna coverage policies are numbered and titled clearly -- always reference the specific policy number
- For prescription denials, Cigna has a separate formulary exception process. Your doctor can request a Formulary Exception through the Cigna provider portal
- Cigna's appeal fax numbers vary by region. Use the fax number printed on your denial letter, not a generic number
- Cigna sometimes offers a voluntary "pre-appeal" review -- take advantage of this if offered, as it can resolve the issue faster
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Aetna (CVS Health)
Loading policies...Aetna, now a subsidiary of CVS Health, covers approximately 23 million people. They publish Clinical Policy Bulletins (CPBs) that describe their coverage criteria for specific procedures and treatments. These bulletins are publicly accessible and very detailed, making them useful for constructing point-by-point appeals.
Aetna-Specific Tips
- Aetna allows 180 days to file an internal appeal
- Aetna Clinical Policy Bulletins (CPBs) are numbered and publicly searchable on their website -- find the relevant CPB and address each criterion
- Aetna uses the InterQual criteria for many medical necessity reviews. If you can get your hands on the relevant InterQual criteria, address them directly
- Since the CVS Health merger, pharmacy denials may go through CVS Caremark. Make sure you are appealing to the right entity
- Aetna has an online appeal submission option through their member portal in addition to fax and mail
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Anthem Blue Cross Blue Shield
Loading policies...Anthem BCBS is part of Elevance Health and operates Blue Cross Blue Shield plans in 14 states. They publish Medical Policies and Clinical UM Guidelines. Note that BCBS plans in different states are operated by different companies -- Anthem covers states like CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, NY, OH, VA, and WI. If your BCBS plan is from another state, the policies may differ.
Anthem BCBS-Specific Tips
- Anthem allows 180 days to file an appeal for post-service claims
- Anthem medical policies are numbered with a "MED." or "SURG." prefix -- cite the specific policy in your appeal
- Anthem frequently uses MCG (formerly Milliman Care Guidelines) for utilization review. These are proprietary but your doctor may have access
- The Blue Cross Blue Shield Association maintains a national Technology Evaluation Center -- if they have evaluated your treatment favorably, cite it
- For multi-state employers, the appeal process may follow the state where the plan is administered, not where you live
- Anthem has separate processes for behavioral health denials, often administered through a behavioral health subsidiary
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Humana
Loading policies...Humana covers approximately 17 million people and has a particularly strong presence in Medicare Advantage plans. If your Humana denial is for a Medicare Advantage plan, the appeal process follows CMS (Medicare) rules rather than standard commercial appeal rules, which gives you additional protections.
Humana-Specific Tips
- For commercial plans, Humana allows 180 days to file an appeal
- For Medicare Advantage plans, you have only 60 days from the denial, but the process moves faster: Humana must decide within 30 days (or 72 hours for expedited)
- Humana Medicare Advantage denials can be escalated to an Independent Review Entity (IRE) and beyond to an Administrative Law Judge -- these later stages have high overturn rates
- Humana publishes Coverage Policies and Medical and Pharmacy Coverage policies -- reference the specific policy number
- For Humana Medicare Advantage appeals, ask your doctor to check the Medicare Coverage Database for National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
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