Many patients know the sinking feeling when they learn a prescription, a specialist visit, a diagnostic test, or an ongoing treatment won’t be covered. Insurance denials are a growing barrier to care, interrupting treatment plans, delaying access to needed services and attempting to defeat patients and their providers.
The good news is that a denial is not the final word. In fact, the data shows that when patients push back and appeal, up to 80% of patients WIN! Yet less than 1% of denials are contested.
Insurance Denials Are Rising
Insurance denials have become a widespread, growing problem across the country. In recent years, insurers have denied a significant share of provider orders for their patients, with some plans rejecting as many as 17% , and far more in certain cases. For patients with chronic conditions, these denials can be especially harmful. Ongoing care depends on consistency and continuity, and disruptions can lead to worsened outcomes, avoidable complications, and higher long-term costs for the patient, the provider and the insurer.
Why Are Claims Denied?
Understanding why claims are denied is key to successfully challenging them. Many denials center on “medical necessity” determinations, where insurers conclude that a treatment does not meet their criteria, even when a physician recommends it. This can include those determined by an AI, by a provider without the specialized knowledge needed and, as some have concluded, simply in an effort to discourage use of benefits (PBS).
Other common reasons given include:
- Lack of prior authorization
- Incomplete or incorrect paperwork
- Out-of-network providers
- Treatments deemed experimental or not covered
- Administrative errors (outdated clinical criteria, inconsistent review processes)
The Overlooked Fact: Many Denials Are Reversed
Perhaps the most important and overlooked fact about insurance denials is how often they are overturned. A recent JAMA study of New York insurance claims found that the share of denials overturned on appeal increased from 38% in 2019 to nearly 53% in 2025. When cases move beyond internal appeals and into external review, the success rates can be even higher:
- Independent reviews overturned 30% to 78% of denials, depending on the type of care.
- In California, about 60% of denials are overturned through independent medical review programs
- Some analyses show that nearly 80% of appealed claims are ultimately reversed when patients persist through the full process.
Independent Medical Review
Independent review is one of the strongest safeguards available to patients. If a patient’s internal appeal is denied, they can request an external or independent medical review, where licensed physicians who are not affiliated with the insurance plan assess whether the treatment is medically necessary. This often happens by filing a complaint with the state oversight department. You can visit MyPatientRight.org to click on your state to learn about how to file a complaint and learn more about Independent Medical Reviews here.
This process:
- Relies on clinical evidence and medical guidelines
- Removes conflicts of interest tied to insurer decision-making
- Results in a binding decision requiring insurers to cover care if overturned
How Can Patients Appeal More Effectively?
Appealing a denial can feel overwhelming, but evidence shows that persistence pays off. Patients can improve their chances by taking a few key steps:
- Understand the reason for denial: Carefully review the denial notice to identify whether the issue involves medical necessity, missing documentation, or coverage rules.
- Gather strong clinical support: Include a detailed physician letter, medical records, and supporting evidence.
- Follow every level of appeal: Keep a close eye on where and how your appeal is proceeding, and get involved as needed.
- Act quickly: Appeals are time-sensitive, and missing deadlines can forfeit the opportunity for review.
- Use trusted resources: Many patients never appeal simply because the process is confusing or unclear. Tools like org — developed by patient advocates — provide step-by-step guidance to help individuals understand their rights and navigate the process.
A System That Needs Fixing
When more than half of appealed denials are reversed, it signals deeper issues in how insurers evaluate claims. Policymakers should take note and work toward reforms that improve transparency, accountability, and oversight of utilization management and simplify the appeals process.
It’s worth noting that policymakers are testing new approaches. The Centers for Medicare & Medicaid Services has launched the Wasteful and Inappropriate Service Reduction (WISeR) Model, which uses technology-enabled prior authorization and clinical review to assess medical necessity. While intended to improve consistency and reduce low-value care, the model is still new, and true reform requires more than new models — it requires transparency.
Insurers should be required to publicly report their denial rates, the clinical criteria used to make medical necessity determinations, and the outcomes of both internal and external appeals. When this data is made available, patients and advocates can identify widespread inappropriate denials, policymakers can create reforms more effectively, and patterns of abuse become impossible to ignore.
California is moving in the right direction with SB 363, legislation that would require health plans and insurers to publicly report denials and modifications of provider-recommended care, while also imposing penalties on plans with excessive Independent Medical Review (IMR) overturn rates. According to the California Department of Managed Health Care, approximately 73% of California IMR appeals result in patients ultimately receiving the requested treatment or service — a striking indication that many denied claims should likely have been approved in the first place. California’s effort reflects a growing recognition that denial and appeals practices are not just isolated administrative issues, but a major national patient access problem requiring stronger oversight, transparency, and accountability.
Appeal, Advocate, Access Care
Patients who appeal often succeed in securing the care they need. But access to care should not depend on persistence alone. Patients deserve timely, evidence-based decisions from the start. If you or a loved one receives an insurance denial, don’t stop there. Visit MyPatientRights.org to learn how to appeal, understand your rights, and take the next step toward accessing the care you deserve.
Because for people living with chronic conditions, denied should never mean defeated.