Common insurance denial reasons
What each major denial category means, why it's appealable, and how to win the appeal. Each page connects to the relevant CARC codes, federal regulations, and clinical guidelines DenialHelp uses to draft your letter.
'Duplicate therapy' denials
The plan flagged your medication as duplicating another drug you're already taking. Appealable when the combination is clinically intended.
'Experimental / investigational' denials
The plan called the treatment experimental. Often misapplied — and reversible by citing FDA approval, peer-reviewed evidence, and specialty-society guideline support.
'Not FDA-approved' denials
The plan says the drug or its specific use isn't FDA-approved. Distinct from 'experimental' — and appealable when off-label use is medically supported.
'Not medically necessary' denials
The single most common appealable denial. The insurer says the treatment isn't medically necessary based on its internal coverage criteria — and most are reversible with the right clinical guideline + insurer-policy citation.
'Prior authorization required' denials
The service required pre-approval that wasn't obtained. Appealable when the auth was attempted, when the service was urgent, or when the plan changed PA requirements mid-year.
Non-formulary drug denials
Your drug isn't on the plan's formulary. Appealable via the plan's formulary exception process — which federal law requires plans to maintain.
Quantity-limit denials
The plan capped how much of a medication or service it'll cover per period. Appealable when the higher quantity is medically necessary.
Step-therapy ('fail-first') denials
Step therapy requires you to try and fail a cheaper alternative first. Appealable when you've already tried it, when it's medically inappropriate, or when the required drug is on shortage.
Contact: hello@denialhelp.com