Your doctor says you need the procedure. You agree you need the procedure. Your body certainly agrees. But there's a person at an insurance company — someone who has never examined you, may not practice in your specialty, and is evaluated partly on denial rates — who has decided you don't need it. At least, not yet. At least, not the way your doctor proposed.
This is prior authorization denial, and if it just happened to you, here's what to do about it.
Understand what happened and why
A prior authorization denial doesn't mean the procedure is medically unnecessary. It means the insurance company wants more justification, prefers a different treatment path, or has determined that the request doesn't meet their specific coverage criteria — criteria that may or may not align with current medical evidence.
The denial letter should include the specific reason for denial and the clinical criteria used. Read it carefully. Common reasons include insufficient documentation (your doctor didn't provide enough records), step therapy requirements (the insurer wants you to try a cheaper option first), out-of-network provider (the insurer doesn't have a contract with the proposed facility), and medical necessity dispute (the insurer's reviewer disagrees with your doctor's assessment).
Each reason has a different appeal strategy.
Step 1: The internal appeal
You have the right to an internal appeal, and you should exercise it immediately. Under the ACA, insurers must complete internal appeals within 30 days for non-urgent requests and 72 hours for urgent ones.
What to include: A letter from your treating physician explaining why this specific treatment is medically necessary for your specific case. Any relevant medical records, imaging, lab results, or prior treatment documentation. Peer-reviewed clinical guidelines supporting the proposed treatment. A personal statement describing how the condition affects your daily life.
Your doctor's office handles these appeals routinely. Ask them to submit a peer-to-peer review — a phone call between your doctor and the insurance company's reviewing physician. These calls overturn denials more often than paper appeals alone, because it's harder to deny a request when a specialist is explaining the clinical reasoning in real time.
Step 2: External review
If the internal appeal fails, you have the right to an independent external review. This sends your case to a third-party reviewer who has no relationship with your insurance company. External reviews overturn denials in a significant percentage of cases because the external reviewer applies clinical evidence rather than insurance company coverage criteria.
Your denial letter will include instructions for requesting an external review. The review is free to you. Most states require a decision within 45 days, or 72 hours for urgent cases.
Step 3: Regulatory complaints
If both internal and external appeals fail, you can file a complaint with your state insurance commissioner. Insurance regulators have the authority to investigate denial patterns and impose penalties. This rarely reverses an individual decision quickly, but it creates a paper trail and applies pressure.
For employer-sponsored plans governed by ERISA (most employer plans), complaints go to the U.S. Department of Labor.
The timeline problem
Here's what the appeals process doesn't solve: time. An internal appeal takes up to 30 days. An external review takes up to 45 more. If you file a regulatory complaint, add months. During this entire period, you're waiting — in pain, with declining function, with growing anxiety — for permission to receive care your doctor has already determined you need.
For some conditions, this delay isn't just frustrating. It's medically harmful. Joints deteriorate further. Fertility declines with age. Dental conditions worsen. The procedure you needed six months ago may become more complex and more expensive by the time approval comes through.
The parallel track: don't wait for permission
Filing an appeal and exploring alternatives are not mutually exclusive. While your appeal is in process, you can get a quote from a JCI-accredited facility abroad. If the appeal succeeds, wonderful — proceed domestically with coverage. If it doesn't, you have a fully vetted, dramatically cheaper alternative ready to go.
This isn't an either/or. It's a both/and.
| Scenario | Appeal Route | Medical Tourism Route |
|---|---|---|
| Timeline | 2–6 months (appeal + external review) | 2–4 weeks to schedule |
| Out-of-pocket if approved | Copay + deductible ($2,000–$10,000) | N/A |
| Out-of-pocket if denied | Full U.S. price ($15,000–$55,000+) | $3,500–$12,000 (all-in) |
| Provider choice | In-network only | You choose the surgeon |
| Scheduling | Weeks to months after approval | Days to weeks |
When medical tourism makes the most sense after a denial
Elective procedures with long wait times. If the appeal process will take months and you're in pain or declining, getting care now at a JCI-accredited facility abroad may be the better medical decision, not just the better financial one.
Procedures with high domestic out-of-pocket costs. Even with insurance approval, many procedures leave patients with thousands in copays and deductible obligations. If your OOP cost after approval would be $8,000 and the all-in cost abroad is $6,000, the math favors going abroad.
Procedures insurance doesn't cover well. Dental restorations, cosmetic procedures, fertility treatments (in non-mandate states), and weight loss surgery often have limited or no coverage. A prior auth denial for these procedures is effectively permanent — appeals rarely change the coverage structure itself.
The bottom line
Appeal the denial. Absolutely. The system should work, and fighting for your coverage is worth the effort. But don't let the appeal process be your only plan. While you're waiting for a bureaucratic decision about care your doctor already recommended, know that the same procedure — same quality, same implants, same medical standard — is available at a JCI-accredited hospital for a fraction of the cost, with a scheduling timeline measured in weeks, not months.
The insurance company controls whether they pay for your care. They don't control whether you receive it.