Prior authorization required: how to appeal
The insurer required pre-approval that was not obtained before the service. Retrospective authorization based on medical necessity.
Why this denial happens
- Provider's office did not file the request
- Authorization expired before the service
- Authorization was for a different code
What overturns it
- Retrospective authorization based on medical necessity
- Documentation that authorization was filed and timed out
- Emergency exception
Evidence checklist
- ✓Authorization request submission records
- ✓Medical necessity documentation
- ✓Emergency record if applicable
Some plans allow retrospective authorization within a window (often 30 days). Check the plan's utilization management policy.
Draft an appeal for a "Prior auth" denial
Free analysis identifies the cited policy and missing evidence. Then a finished letter.
FAQ
What does "Prior authorization required" mean on a denial letter?+
The insurer required pre-approval that was not obtained before the service.
How long do I have to appeal?+
180 days from the date of denial for ERISA group plans and ACA marketplace plans. 60 days for Medicare Advantage. Check the denial letter for your specific deadline.
What is the success rate for this kind of appeal?+
Outcomes vary, but medical-necessity and step-therapy appeals overturn at meaningful rates when the appeal cites the insurer's own policy and the chart documents the required criteria.
Other denial reasons
Not legal or medical advice. This page is a self-help resource. You make your own decisions. Strip personal identifiers (name, date of birth, address, member ID) from any document before uploading or sharing. The information here summarizes commonly-published payer policies and federal rules; confirm against your specific plan document and the current denial letter before acting.