How to Win Your Insurance Denial

“The Squeaky Wheel Wins the Appeal”
By Alex Scholz & Mark Moyad, MD, MPH

Getting a denial letter from your insurance company can feel overwhelming, especially when it relates to your cancer care. But denials are not the final answer. Fewer than 1% of denials are appealed, yet more than half of appeals succeed. That means if you take action, your odds are good.

This guide walks you step by step through the appeal process, provides scripts, phone numbers, and links, and connects you with people and organizations who can help you fight back.

Step 1: Read and Understand the Denial Letter

Your denial letter will state the reason for denial, the deadline for filing an appeal, and instructions for next steps.

Tip: Make copies of all denial letters. Write the date you received it at the top. Create a simple binder or folder to keep all your paperwork organized.

Step 2: Peer to Peer Review

A peer to peer review allows your doctor to speak directly with the insurance company’s medical reviewer. More than half of denials are reversed at this stage. Ask your doctor’s office to set up the review. Give your physician a short bullet list of why this treatment or scan is medically necessary in your case.

Step 3: Internal and External Appeals

If peer to peer does not succeed, file a formal appeal.

Internal appeals are handled by your insurance company, usually within 30 to 60 days.

Expedited appeals are available if treatment is urgent and can be decided in as little as 72 hours.

External reviews are independent.
Federal: MAXIMUS Federal Services Tel: 888-866-6205 Fax: 888-866-6190
State: Search “[Your State] external review process” or check your denial letter for instructions.

Tip: Always ask for a written confirmation when you file an appeal.

Step 4: Write a Strong Appeal Letter

A strong appeal letter can change the outcome. Include a patient statement, your doctor’s clinical explanation using NCCN Guidelines, insurance policy references, and supporting evidence like lab results or imaging reports.

AI tools like ChatGPT, Gemini, or Claude can help you draft letters quickly. Always review and edit for accuracy.

Step 5: Online Services

GetClaimable.com makes filing appeals easier with guided forms.
Counterforce.com helps you respond to denials. They report that 75 percent of appeals get approved.

Step 6: Insurance Hotlines

Medicare: 1-800-MEDICARE
Medicaid: cms.gov
TRICARE (Military Insurance): tricare.mil

Every insurer also has a customer service hotline. Ask for their Appeals or Grievance Department.

Step 7: Unsung Heroes

Many people in your support network can help you. Human Resources at your workplace, hospital social workers, nurses, caregivers, and unions often know how to navigate the red tape.

Step 8: Drug and Imaging Companies

Pharmaceutical and imaging companies often have patient assistance programs with nurse navigators. They can provide research support, documentation, and direct contact with insurers.

Step 9: Legal Help

Attorneys who specialize in healthcare can review rights, write appeals, and file complaints. This is not free and should be a last resort. Ask about contingency fees if cost is a concern.

Step 10: Non-Profit Advocacy Groups

American Cancer Society www.cancer.org 1-800-227-2345
Patient Advocacy Foundation www.patientadvocate.org (800) 532-5274
Triage Cancer www.triagecancer.org (424) 258-4628

Quick Checklist Before You File

Keep copies of all paperwork
Know your deadlines
Ask your doctor for strong clinical support
Quote guidelines and your insurance policy
Do not give up after the first no

PCRI’s Commitment

At PCRI, we believe insurance denials should always be challenged. Patients deserve access to care, and persistence pays off.

Remember: Insurance companies often deny by default, betting you will give up. The squeaky wheel wins the appeal. Be that squeaky wheel.