Your Insurance Said No: How to Appeal a Denial (2026)

Every deadline on this page was checked against the federal agency’s own page on August 5, 2026. The source for each one is named so you can take it to your plan.

A denial letter is not the end of the road. It is the insurance company’s first answer, and federal law gives you the right to ask for a second one — first from the plan itself, then from an independent reviewer who does not work for them.

This page walks through that process in plain language: what the deadlines are, who can file for you, and how to ask for a faster decision when waiting is not safe.

Start the clock — the deadline that matters most

The most common way a good appeal fails is that it arrives late. Find the date on your denial notice and mark the deadline on a calendar before you do anything else.

If you have…	You have this long to appeal	Source
A marketplace or job-based health plan	180 days (6 months) from the denial notice	HealthCare.gov
A Medicare Advantage plan	65 days from the date on the denial notice	Medicare.gov
A Medicare Part D drug plan	65 days from the date on the denial notice	Medicare.gov
Original Medicare	By the date printed on your Medicare Summary Notice	Medicare.gov
Any plan — for the outside review afterward	4 months from the final denial	HealthCare.gov

If you already missed a Medicare deadline, ask anyway. Medicare.gov states you may still file and get a decision if you can show good cause for missing it — and gives illness, disability, or an accident that delayed you as examples. Say plainly what happened.

First, find out exactly why they said no

You cannot argue with a reason you do not have. The plan has to put it in writing, and it has to do it on a clock. According to HealthCare.gov, your insurer must notify you in writing and explain why:

• Within 15 days if you were seeking prior authorization for a treatment
• Within 30 days for medical services you already received
• Within 72 hours for urgent care cases

Read the letter for the specific reason. The usual ones are that the plan says the service is not medically necessary, that it is experimental or investigational, that the provider was out of network, or that the benefit is not covered. Each of those is argued differently, so knowing which one you are facing changes what you send.

If the letter is vague, call the plan and ask for the denial in writing with the specific plan language and clinical criteria it relied on. Write down who you spoke to and when.

Step one — the internal appeal

This is the plan reviewing its own decision. You file it with the insurance company.

• You have 180 days from the denial notice to file
• The plan must finish an internal appeal within 60 days when it is for a service you have already received
• Complete every form the plan requires, and keep a copy of everything you send

What tends to make an appeal stronger. Ask the treating doctor’s office for a letter of medical necessity that speaks directly to the reason in the denial letter, and ask whether they will request a peer-to-peer review — a call between your doctor and the plan’s reviewing physician. The doctor’s office does this routinely; you do not have to build the clinical argument yourself.

Step two — the outside review, by someone who does not work for your insurer

If the plan says no again, you can take it to an independent external reviewer. This is the step families most often do not know exists. Per HealthCare.gov:

• File a written request within four months of the date you receive the final denial
• A standard external review is decided no later than 45 days after the request is received
• An expedited external review is decided no later than 72 hours, or less, depending on medical urgency
• Your insurer is required by law to accept the external reviewer’s decision

What can go to external review: any denial involving medical judgment where you or your provider disagree with the plan; any denial that calls a treatment experimental or investigational; and cancellation of coverage based on the insurer’s claim that you gave false or incomplete information when you applied.

What it costs. Nothing under the federal process. If your insurer uses an independent review organization or a state process, you may be charged — but the charge cannot be more than $25.

You do not have to file it yourself. You may appoint a representative who knows about your medical condition — HealthCare.gov names your doctor or another medical professional — to file the external review on your behalf.

Important right now: the federal external review process is paused

What this means for you. Most people are not affected, because most states run their own external review process and most plans use it. If your plan does not use the federal process, HealthCare.gov’s instruction is to follow the directions in the notice from your plan or issuer about where to request external review — look at your Explanation of Benefits (EOB) or at the final denial letter, which gives the contact information for the organization that will handle it.

Do not let this stop you from filing on time. File within your four-month window through whatever route your denial letter names, and keep proof of the date you sent it.

This is an active situation. We re-check this section quarterly. If you are reading this well after the date above, confirm the current status on HealthCare.gov before relying on it.

If waiting is not safe — the fast track

There is a faster lane, and a doctor can open it.

• You can file an expedited appeal if the standard timeline would seriously jeopardize your life or your ability to regain maximum function
• In urgent situations you can request an external review without finishing the plan’s internal appeals, and you may file both at the same time
• An expedited decision must come as quickly as your condition requires and at least within 4 business days; it can be given verbally but must be followed by written notice within 48 hours
• On Medicare drug plans, the request is expedited if the plan determines, or your prescriber tells the plan, that waiting may seriously jeopardize life, health, or the ability to regain maximum function (Medicare.gov)

That last point is worth carrying into the next appointment: on the drug side, the prescriber saying so is enough to trigger the fast track.

If you are on Medicare, the path has five levels

Most people never go past the first two. But the ladder exists, and each rung has its own clock.

Original Medicare (Medicare.gov)

1. Redetermination — file by the date on your Medicare Summary Notice; a decision generally comes within 60 days
2. Reconsideration — you have 180 days after the level 1 decision to ask a Qualified Independent Contractor, which decides within 60 days
3. Administrative Law Judge, then Medicare Appeals Council, then federal district court — each has a 60-day window from the previous decision

Medicare Advantage (Medicare.gov) — file within 65 days. Response times are 30 days for a pre-service appeal, 60 days for a payment appeal, 7 days for Part B drugs, and 72 hours for a fast appeal; these may be extended by up to 14 days in some cases.

Levels 3 and 5 require the case to meet a minimum dollar amount, which changes each year. Medicare.gov lists the current figure.

If the denial is about a clinical trial

Trial costs come in two kinds, and mixing them up causes denials. The National Cancer Institute separates research costs — the study drug, lab tests done purely for research, added imaging done solely for the trial, and extra doctor visits you would not have with usual care — from the routine patient care costs you would have had anyway.

• Medicaid covers all routine patient care costs in a clinical trial
• With Medicare, you may be reimbursed for some of the costs of taking part in trials of new ways to diagnose or treat cancer
• Under TRICARE, you can be reimbursed for medical costs of taking part in NCI-sponsored cancer prevention and treatment trials

Two questions before enrolling, both from NCI’s own list: does the health plan cover routine patient care costs for people in clinical trials, and if so, is pre-authorization required? Ask the research coordinator whether other people have had trouble getting their plans to cover routine care. And ask for the study’s billing manager — NCI notes they may know how to appeal your plan’s decision.

Free help exists — you do not have to do this alone

• Your state’s Consumer Assistance Program or Department of Insurance helps people file internal appeals and external reviews at no cost
• HealthCare.gov, 1-800-318-2596, for marketplace coverage questions
• 1-800-MEDICARE (1-800-633-4227) for any Medicare appeal question
• The hospital’s oncology social worker or financial navigator — they do this every week, and asking costs nothing

A short checklist you can work from

1. Find the denial letter and write the date at the top of a folder
2. Count your deadline from that date and put it on a calendar
3. Call the plan and get the specific reason and criteria in writing
4. Ask the treating doctor’s office for a letter of medical necessity and a peer-to-peer review
5. File the internal appeal, keep a copy of everything, and note the date you sent it
6. If it is denied again, file the external review within four months
7. If waiting is dangerous, say so — ask for the expedited track and have the doctor say so too

Not sure which benefits you qualify for?

A denial on one path does not close the others. Mesothelioma families are often eligible for aid programs, grants, and earned benefits at the same time as they are appealing a coverage decision.

Call 1-800-877-6000 to talk it through with a Patient Advocate — there is no cost for the conversation.

See also our verified grants and financial assistance directory, our mesothelioma specialty center directory, and the main financial assistance guide.

For resource-page editors, social workers and nurse navigators

You are welcome to link to or cite this guide. Every deadline is attributed to the federal source that states it, and we re-check the whole page on a recurring basis and date-stamp the check — including the FERP status above, which is currently changing. Spot something we got wrong? Tell us on our contact page and we will correct it.