How External Appeals Can Help Patients Fight Insurance Denials

Many patients accept a health insurance denial without realizing they have the right to challenge the decision through internal and external appeals. External reviews, introduced more broadly under the Affordable Care Act, allow independent medical experts outside the insurance company to evaluate denied claims. If the reviewer overturns the denial, the insurer is legally required to pay for the treatment.

The article highlights the case of a North Carolina couple whose insurance company repeatedly denied coverage for intensive psychiatric care despite multiple suicide attempts by the patient. After discovering instructions for an external review buried deep within a denial letter, the family appealed. An independent physician reviewed the case and overturned the denial, forcing the insurer to cover more than $70,000 in treatment costs.

Health policy experts stress that patients should always appeal denied claims because insurers often expect patients to give up due to stress, illness, confusion, or unclear instructions. Consumer assistance programs in some states help patients understand denials, gather documents, and file appeals free of charge. Studies show these programs can successfully overturn many denials.

The article also explains that patients should keep all denial letters and medical records, understand deadlines for appeals, and seek help from doctors or advocacy programs. External reviews are especially important for denials involving medical necessity, experimental treatments, or urgent care situations. Experts emphasize that persistence and knowledge of appeal rights can sometimes make the difference between receiving necessary treatment and going without care.

Here is the APA citation:

Eldeib, D. (2025, October 7). This little-known appeal could force your insurer to pay for lifesaving care. Here’s how to file it. ProPublica. https://www.propublica.org/article/health-insurance-denial-external-review