What does the denial notice actually tell you?
Everything the appeal needs is anchored in that one document. Pull seven things out of it before you write a word. The first four are the decision being made, the stated reason, the plan provision it cites, and the review route offered. Then take the deadline, the address or portal where the appeal goes, and whether an urgent (expedited) process is described. If the notice is unclear or the clock is short, contact the plan through its official channel and ask for each answer in writing.
Which appeal rulebook applies to you?
Employer plan: self-funded (your employer, not the insurer on your card, pays the claims) or fully insured? Marketplace? Original Medicare, Medicare Advantage, or Medicaid managed care? Your plan documents, HR office, or member card can tell you which one applies.
Open your lane
Self-funded employer plans under ERISA (the federal law covering most employer health plans)
For an ERISA-covered self-funded employer plan, the federal claims rule requires at least 180 days after receipt of an adverse benefit determination to appeal. For post-service claims, a one-level process generally decides within 60 days; for pre-service claims, generally within 30 days. A two-level process generally uses no more than half of the applicable period at each level. Evidence
Fully-insured employer and other state-regulated plans
HealthCare.gov describes 180 days to file an internal appeal for covered individual and group plan decisions, with a general 30-day decision period for a service not yet received and 60 days for a service already received. Where external review is available and the decision qualifies, the general request window is four months after the final internal denial; the notice and governing state or federal process control. Evidence Evidence
ACA Marketplace plans
HealthCare.gov describes a 180-day internal-appeal window for Marketplace coverage and, for eligible final internal denials, a general four-month external-review request window. As checked August 13, 2026, HealthCare.gov also says the HHS-administered Federal External Review Process has been temporarily unavailable since July 1, 2026, for Alabama, Florida, Georgia, Texas, Wisconsin, and US territories other than Puerto Rico. Current state or federal availability, the denial notice, and the plan documents control the actual route. Evidence Evidence
Original Medicare
For Original Medicare, CMS describes 120 days from receipt of the initial determination to request the first-level contractor redetermination, with a general 60-day decision period. Later levels may include reconsideration, an administrative-law-judge hearing, Medicare Appeals Council review, and federal court review; each decision notice controls the next step. Evidence
Medicare Advantage
For Medicare Advantage, the standard reconsideration request period is 60 calendar days from receipt of the organization determination, subject to a good-cause extension. If the plan affirms an adverse reconsideration, it must send the case to the independent review entity. The regulation sets different decision periods for standard service, payment, and expedited cases; the denial notice controls the applicable route and date. Evidence Evidence
Medicaid managed care
Federal Medicaid managed-care rules give 60 calendar days from the adverse-benefit-determination notice to request a plan appeal. A state fair hearing generally follows completion of the plan appeal, unless the plan misses specified timing or notice requirements. The state must select a fair-hearing request period of no fewer than 90 and no more than 120 calendar days after the appeal-resolution notice. Evidence Evidence
See all six lanes side by side, with the published first-appeal window and next step
| Coverage regime | First appeal window (published rule) | What comes next |
|---|---|---|
| Self-funded employer (ERISA) | At least 180 days to file an internal appeal | External review may follow; the Department of Labor oversees the plan |
| Fully-insured employer / state-regulated | 180 days to file an internal appeal | External review may be available; the denial notice and state route control |
| ACA Marketplace | 180 days to file an internal appeal | External review may be available; current federal or state instructions control |
| Original Medicare | 120 days to request redetermination | Later appeal levels may follow; each decision letter names the next step |
| Medicare Advantage | 60 calendar days to request reconsideration | An upheld denial is forwarded to the independent review entity |
| Medicaid managed care | 60 calendar days to appeal with the plan | A state fair hearing may follow; the state-selected window is 90–120 days |
Rules change; your own notice, plan documents, and current official instructions control.
If external review still does not fix it, or the problem is how they handled your claim
For an eligible decision, HealthCare.gov describes a standard external review as decided no later than 45 days after the request is received, or no later than 72 hours if expedited. It says the insurer is required by law to accept a decision in your favor. A complaint to your state department of insurance is a separate route. It can investigate unfair claim delays or denials, failure to honor the policy, or lack of timely communication, and can require the insurer to correct a problem it finds. Evidence Evidence
A department of insurance complaint looks at how the insurer handled the claim. It does not re-decide whether the treatment was medically necessary the way external review does. A self-funded employer plan under ERISA (the federal law covering most employer health plans) is generally not the kind a state department of insurance regulates; the Department of Labor oversees those instead, so confirm which regulator applies to your plan before filing.
Does the appeal answer the reason they actually gave?
A medical-necessity denial, a benefit exclusion, a missing prior authorization (your insurer's approval, required before it will pay), a network or supplier issue, a coding mismatch, and an “experimental” determination are six different problems. A letter that argues the wrong one does not address the decision that was made. Your clinician can supply the clinical half; the plan-document and process half falls to you or your authorized representative. Send what answers their reason, and nothing else.
What goes in the envelope?
Start from the appeal letter template (.docx) (opens in a new tab) and attach, in this order:
- A copy of the denial letter - keep the original; the appeal should quote the exact denial reason back at the reviewer.
- The written order, naming the device by its HCPCS code - E0691 through E0694, matching the device actually requested. A code-device mismatch is an easy reason for a claim to bounce.
- The policy citation - the insurer’s own criteria document for your condition, named by number (for instance Aetna CPB 0422 (Aetna's written medical policy document) for vitiligo, Aetna CPB 0205 for psoriasis, or Anthem CG-DME-41; the coverage table lists the document each insurer uses), with the relevant paragraph marked.
- A physician letter that names each prior treatment, with dates and results - some policies require prior-treatment documentation. Confirm the condition-specific rule - for example, Aetna CPB 0422 for vitiligo or CPB 0205 for psoriasis - and do not treat meeting a public criterion as approval. Some policies also ask why home rather than a clinic. The medical-necessity-letter guide covers the full contents, including the supervision and follow-up plan.
- Chart notes that back every statement in the letter - the letter is a summary; the records are the evidence.
- Proof of prior authorization, where the plan’s list requires it - an unauthorized claim can be denied on process alone, with the criteria never reviewed.
- An efficacy citation, if the denial says “experimental” - the template holds a slot for the LITE study. That is a pragmatic trial of 783 people with psoriasis published in JAMA Dermatology in 2024, which compared home and office narrowband UVB head-to-head. Fill the slot with what fits your condition and let your clinician confirm the citation.
Starting point · not legal advice
A letter skeleton, not a magic script
Starting from a blank page is hard. Replace every bracket with your facts. Your clinician’s records and letter carry more weight than polished wording.
Re: Appeal of denial - claim #[claim number], [date] I am appealing the denial of [requested treatment or home device], denied as “[exact reason from the notice].” [Use one or two sentences from your clinician about your diagnosis and documented impact.] My treating clinician, [name], prescribed this treatment because [clinical reason from the enclosed letter of medical necessity]. [If it applies] Clinic care is hard to reach because [documented distance, schedule, or other barrier]. The records enclosed show the relevant clinic and equipment costs. Under [exact section of my plan, if known], I request reconsideration. Enclosed: [list only the records you are actually sending]. Please respond through the review process and timeline stated in my denial notice.
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Records to consider enclosing
- the denial notice;
- the prescription or order;
- your clinician’s letter and relevant records;
- only the plan pages and supporting records that answer the denial reason.
Deadlines and routes are plan-specific. Use the exact notice and official plan channel. This is general education, not legal advice.
Which records should you keep, and for how long?
Keep the original denial, the governing plan document, and the original request. Keep everything you submitted, proof the plan received the appeal, every later decision, and dated notes from every call. Send copies and preserve the originals. If your insurance comes through work, ERISA may let you request plan documents in writing. If the reason given was “not medically necessary,” your treatment log and photos are appeal evidence too - see what to record and why.
Practical tip - not legal or benefits advice
Why dated call notes help
Write the date, the representative’s first name and the reference number after every call. When an explanation of benefits contradicts what you were told, that note is what you quote.