Do You Know How to Appeal an Insurance Claim Denial? You Can Learn and Practice Financial Self-Defense.
Hi Friendos,
Today I am revisiting an insurance topic I last wrote about two years ago, appealing when your medical insurance denies a claim. I have learned a lot about appeals in the last two years and would like to share what I can with you. Like many other parts of personal finance, our health finance system is not what it should or could be, but I still want to help you squeeze that lemon for everything it’s worth!
If you’ve never had a claim denied by your medical insurer, that is amazing. Also…sadly…you probably just need to wait until you get one. To be forewarned is to be forearmed.
My guide, inspiration, and motivation throughout this process has been the excellent Arm and a Leg podcast, which I have mentioned here before. Two excellent episodes about insurance appeals are:
- December 2021: featuring Jacqueline Fox, a lawyer who draws a straight line from the English enclosure movement to current-day U.S. medical insurance, and
- November 2021: featuring Laurie Todd, “The Insurance Warrior,” who has won hundreds of appeals, including one for her own life-saving surgery. Todd has two excellent and inexpensive e-books about appeals which I personally found helpful and motivating.
My hero’s journey began in October 2025, when I went to fill a prescription and Cigna denied prior authorization. It ended in August 2026 when the denial was overturned and Cigna mailed me a check to reimburse my out-of-pocket costs. I won! I won! I won!
I will need this prescription medication for the rest of my life. Multiple doctors told me that “insurance never covers it” for women. Despite what was happening in my body and what my doctors said, my insurance company’s denial letter stated this medication is “medically necessary” only for men in certain situations. Ooh that made me mad! The perfect fuel for me to righteously grind through some administrative hoops.
Now I’ll walk through my appeal timeline so you can see the specific steps involved. At the end, I’ll summarize some lessons learned. Throughout this process, I took advantage of the time permitted for appeals; I kept it on my to-do list, stayed aware of the deadlines, and did the admin work when it fit into my schedule:
Oct 2025: Attempt to fill prescription at neighborhood pharmacy (shop local!) and am informed I need prior authorization from Cigna, my medical insurance company.
Nov 2025: Cigna sends a letter denying prior authorization for the phony baloney reasons discussed above. The fine print explains how I can appeal this decision:
Nov 2025: I pay out of pocket to have the medicine in hand and avoid health problems from interrupting care.
Feb 2026: I mail my “internal appeal” letter to Cigna’s Appeals and Grievances department. I include bloodwork results from before and after I started treatment, showing my good response to the medication, in case Cigna did not have those when it initially denied authorization.
Early-April, mid-April, and May 2026: In three separate phone calls with Cigna I ask about the status of my internal appeal. First Cigna says they never received my letter but I can verbally appeal over the phone. Then they say my verbal appeal was rejected because it failed to include required info about my copay, deductible, and coinsurance. Then they say my appeal needs to be resubmitted with appropriate information. What? Okay, I read them the same info from my original internal appeal letter.
I don’t know why it took three tries, perhaps the first two reps I spoke with just weren’t familiar with the process. After all, 99% of denials are not challenged even though most challenges ultimately win. (If you want to deep dive, check out this excellent KFF study.)
Jun 2026: I receive a letter saying I lost my May 2026 verbal appeal based on the same rubbish reasons as the initial denial. The fine print explains how I can request an “external appeal”:
Jul 2026: I assemble and submit my external appeal letter. In New York State, where I live, you can do this online. I found the actual submission process straightforward.
I spent a lot of time on my cover letter, though it would not take me nearly as long if I were to do another one in the future. I customized things for my new audience, an independent physician who was not a direct Cigna employee. I had learned that NY Insurance law required this reviewer to consider (1) the insurance company’s clinical criteria, (2) generally accepted clinical practice guidelines developed by professional medical societies, (3) my doctor’s recommendation, and (4) my medical information, so I organized my appeal around these four areas.
I included full copies of clinical practice guidelines addressing my medical condition, which were easy to find online. My goal was to put all the relevant info in front of my reviewer in a very organized way, making it easy for them to agree that I was right and Cigna was wrong.
Cigna’s denial asserted that there are “not enough current, published medical studies” demonstrating effectiveness of this medication for my condition. Therefore, my letter quoted from the clinical guidelines: “Over the past 2 decades, multiple publications consisting of original research, reviews, and meta-analyses have supported [use of this medication for my medical condition].”
Jul 2026: I receive an acknowledgment letter that my appeal was received, giving me a 3-business-day window to submit any additional materials and stating my review would take place within 30 days.
Aug 2026: I receive the reviewer’s determination. The cover page states: “The reviewed has decided to overturn the health plan’s decision.” VICTORY!
The reviewer found that Cigna did not act reasonably with sound medical judgment, did not act in my best interest as a patient, and found that my prescription was medically necessary. Their report cited all three of the clinical guidelines I included with my appeal as well as the lab results and clinical notes from my doctor appointments.
Late Aug 2026: I receive a letter from Cigna stating my prescription is covered under my plan, as well as a check from Cigna in the amount I had previously paid out-of-pocket. The letter also stated, “I have made the necessary arrangements to have the pharmacy authorization case number [XYZ case #] updated as approved for one year from August 17, 2026, through August 17, 2027.”
Phew! I did it!
Observations and lessons learned:
- Although I ultimately got reimbursed, I did need to pay for my medication upfront and there was no guarantee of reimbursement. A fully funded emergency fund is crucial.
- At the end of each phone call with Cigna, during which I took written notes, I made sure to get the representative’s name and a reference number for the call. During future calls, representatives used the reference number to look up info from my prior calls – I did not have to repeat every single thing from prior discussions. Always ask for a reference number.
- If your insurance company has problems processing snail mail, try another communication method. It is possible to send a fax online or via email – you do not need to own a fax machine or pay-per-page at UPS-type store. If you send a fax online, be sure the service has some cybersecurity measures in place and is HIPPA-compliant, unlike most free online fax websites. I’ve used Dropbox for sending online faxes in the past.
- None of my appeals discussed sexism, my anger or other feelings, or the impact on my life of any of this. None of those factors would have been considered relevant by the people making decisions, even though they all felt relevant to me. Insurance is a contract and this was a contract dispute.
So, now that I won my appeal, I live happily ever after? Well, the approval Cigna said they were giving me for a year was incorrectly applied to my (male) spouse’s Cigna account instead of my account. That is why Cigna denied prior authorization last month when I went to refill my prescription, and again I had to pay out of pocket. I called and finally got a rep who explained the situation and worked with their colleagues to correct the error. My next reimbursement request should end with me getting a check in the mail🤞.
Overall my feelings about this are well-expressed by Artie Vierkant on the 8/3/2026 episode of the Death Panel podcast, “Medical Frailty”:
“Every single one of us should be sick and tired, are sick and tired of health care, and health insurance, demanding this extraordinary ransom from us to buy our survival.”
I have had other appeals sail right through and then I had this one which was stupidly arduous. You have to decide what level of effort is worth it to you, and sometimes you can ask to have a claim “reprocessed” and entirely bypass the formal appeal process. Just know that the appeal process exists, you don’t need any special training or background to file an appeal, and loads of people WIN their appeals.
-Stephanie
