The questions a denial raises

Denise Ramirez, Coverage Editor · Updated August 2026

• What does your denial letter have to tell you?More than most letters say. Federal rules require the specific reason, the plan provision, what else you would need to send, the denial code, and the internal criterion, free on request. Ask for whatever is missing.
• Are your appeal rights set by your state or by Washington?Mostly by whether your employer buys insurance or pays claims itself. Insured coverage in a qualifying state uses that state's external review; a self-funded plan usually does not. A handful of states run no process at all.
• What does “not medically necessary” actually mean?It means your file missed a specific written criterion, not that your doctor was wrong. The plan has to explain the clinical judgment it applied to you, or send that explanation free on request. Get the criterion first.
• Does prior authorization mean your plan covers it?Neither yes nor no, and the difference decides what you do. Prior authorization means the drug is on your formulary behind a gate with written criteria you can demand. An exclusion means it is not there at all.
• Can an appeal deadline be extended?Sometimes, and it depends entirely on the route. A Medicare Part D plan may extend for good cause if you ask in writing. Commercial plans have no such provision. Medicaid leaves it to your state.
• What is the difference between a formulary exception and a prior authorization?A prior authorization asks your plan to apply its own rule. A Part D formulary exception asks it to set the rule aside, needs your prescriber's supporting statement, and must be granted once the drug is found medically necessary.
• Can your doctor's office appeal for you?Yes on every route, and on two of them without paperwork. A Part D prescriber can act without being an appointed representative. In an urgent commercial claim, a treating professional must be allowed to act.

How these are written

The answer goes in the first forty words, whatever it turns out to be — including when it is “no,” “it depends on something you can go and check,” or “nobody publishes that.” Every figure on the page is carried by a sourced fact rather than by prose, so a number cannot quietly drift away from the document it came from.

We read the regulations themselves rather than summaries of them, and we say where the text is silent instead of filling the gap. Between these 7 pages we cite 21 distinct documents, each with the month we opened it.

None of this is legal or medical advice. If you want the procedure rather than the rule, the procedures pages set out what to file and when, and the deadline calculator counts to the dates from the date on your own notice.