The next time your health insurance denies a medication or procedure, here's how to appeal it. You'll probably win.

MW The next time your health insurance denies a medication or procedure, here's how to appeal it. You'll probably win.

By Archelle Georgiou

Your insurer is betting you won't appeal - but research shows 1 million denials could have been overturned if patients pushed back

In an analysis of six Medicare Advantage plans covering more than 23 million members, there were more than 1.9 million denials. Of the 7% who appealed, 66% got their appeals overturned.

David is 73 years old and has osteoporosis with a history of multiple fractures. Despite trying a series of medications, his bone density continued to decline. In June, his endocrinologist recommended Amgen's $(AMGN)$ Prolia, an injection proven to reduce fracture risk, but he didn't receive his first dose until January - seven months later.

Why the delay? Prior authorization, which is the approval process health insurers require before agreeing to pay for certain procedures or medication. For David, navigating this process meant spending ten hours on the phone and resubmitting the same clinical documentation three times. The delay also cost him $2,000 out of pocket. David's deductible had reset, and costs his insurer would have covered in December became David's problem in January. So David lost time and bone while the insurer benefited financially from this delay.

David is my husband. His story is the rule, not the exception.

I've spent the past several weeks analyzing prior authorization data made available under the Center for Medicare & Medicaid Services' Interoperability and Prior Authorization Final Rule, which required health plans to publish this information for the first time by March 31.

In my analysis of six Medicare Advantage plans covering more than 23 million members, there were more than 1.9 million denials, about 10%. Only 7% appealed their denials, but for those who did, 66% of those appeals were overturned.

When an appeal is overturned, it suggests that the initial denial was wrong. The error with any individual issue may lie with the insurer, the provider or the patient. Regardless of the reason, data showing that it happens a majority of the time points out a systemic flaw. It's what engineers call a defect.

In most industries, a high defect rate is a problem to fix because it wastes time and money. Imagine if your credit card company declined every tenth transaction, reviewed and approved them only if you called, and then determined that more than half of the charges were not fraudulent at all.

That's not effective fraud protection. That's a broken system that is wasting money and creating friction with customers and vendors. Credit-card issuers are motivated to improve the process because getting it right the first time saves money.

In most industries, a 66% defect rate would trigger an immediate focus on process improvement. In health insurance, that doesn't happen. The financial incentives are aligned to maintain the friction. Insurers are not motivated to get it right the first time because denials are rarely appealed. And when a patient doesn't appeal, the denial stands and the insurer saves the cost of the service.

My analysis suggests that 1.13 million denials would likely have been overturned if patients had appealed. Since they weren't, four health insurance companies pocketed between $100 million to $500 million in claims they never had to pay. That money represents care - recommended by physicians - that patients never received because they didn't know they could fight back.

Why AI won't fix the problem

The human cost of that friction is documented. A 2024 survey conducted by the American Medical Association found that 93% of physicians report prior authorization causes delays in care. Twenty-three percent said it had led to a patient's hospitalization. Eighteen percent reported that it led to a life-threatening event or required an intervention to prevent permanent harm. A systematic review of 25 studies published this year in The American Journal of Medicine found that prior authorization delays were associated not just with hospitalizations but with lower rates of disease-free survival.

And now we are scaling the model that negatively impacts patient outcomes.

The WISeR program - which stands for Wasteful and Inappropriate Service Reduction - is a CMS pilot program that introduced AI-driven prior authorization to traditional Medicare beneficiaries in six states earlier this year. Results from the first three months, according to patient advocacy groups, are troubling: denial rates in some states are running even higher than in Medicare Advantage plans. A Medicare official recently said that paying for care that isn't clinically appropriate is "just not something we should accept as Americans." I agree. So why are we accepting a prior authorization system that causes demonstrable harm? And why are we now running it at scale, with AI, before fixing the incentive structure underneath it?

WISeR is, in effect, an experiment on Medicare patients. When clinical trials raise safety concerns, they are paused, redesigned or halted. The same standard should apply here.

How to appeal a denial

Policymakers should treat a 5% overturn rate as the minimum quality threshold - the same bar we set for clinical processes - and require AI vendors to meet it before continuing the program. Anything higher isn't a pilot with growing pains. It's a system causing harm at scale.

But policy change is slow. While we wait, here's how to work the system if you experience a denial:

-- Get a written copy of the denial letter and look for the specific reason cited for the denial.

-- Appeal every denial in writing. Provide specific information that counters the reason they cited.

-- Ask your physician's office to submit an appeal on your behalf and get a copy for your records. This is not duplicative. Your appeal letter is complementary to your physician's.

-- Track deadlines aggressively. Both initial decisions and appeal reviews are subject to regulatory timeframes that insurers are required to meet.

-- If your appeal is denied, escalate to your state insurance commissioner. Regulators notice patterns.

The process is designed to feel difficult. Do it anyway. With appeal overturn rates running at 60% or higher, that's not a flaw in the system. It's the system working exactly as the incentives intend. And we can each take steps to change it.

Archelle Georgiou is a physician, journalist and former healthcare executive. She was chief medical officer at UnitedHealthcare and currently serves on the boards of the Children's Minnesota hospital and the medical device company Nuwellis. Georgiou is the author of "Healthcare Choices: 5 Steps to Getting the Medical Care You Want and Need," hosts a podcast called Speak Up For Your Health and writes a Substack to help Americans understand how healthcare really works.

-Archelle Georgiou

This content was created by MarketWatch, which is operated by Dow Jones & Co. MarketWatch is published independently from Dow Jones Newswires and The Wall Street Journal.

(END) Dow Jones Newswires

April 22, 2026 14:40 ET (18:40 GMT)

Copyright (c) 2026 Dow Jones & Company, Inc.