Prior Authorization Denied?
They're Counting On You To Give Up.

Prior authorization is insurance pre-approval required before certain medications or treatments. Denials happen for multiple reasons: cost management (insurers save $7B annually), step therapy requirements (forcing cheaper alternatives first), "not medically necessary" claims, administrative errors, or off-label use objections.

The good news: most prior authorization denials can be overturned with a proper appeal that includes clinical evidence, guideline citations, and your doctor's medical justification. Your odds increase by orders of magnitude just by fighting back.

Standard appeals: You typically have 180 days from the denial date to file an internal appeal. The insurer then has 30 days to decide (or 60 days if they request an extension).

Urgent appeals: For serious health risks or immediate treatment needs, you can request expedited review. The insurer must decide within 72 hours. If denied, you can escalate to external review immediately (another 72 hours).

Don't delay—insurers count on appeal fatigue. The sooner you appeal, the better your chances.

GLP-1 drug denials have surged 400% due to high costs ($968-$1,349/month) and confusion about FDA-approved uses:

• Ozempic: Approved for type 2 diabetes, often denied for weight loss (off-label)
• Wegovy: Approved for obesity, denied if lifestyle modifications not documented
• Mounjaro: Approved for diabetes, requires step therapy (trying metformin first)

Why we win GLP-1 appeals: We cite FDA approvals, clinical guidelines (AACE, ADA), and document medical necessity including comorbidities (diabetes + obesity + cardiovascular risk). Most denials are rubber-stamped—a proper appeal forces actual medical review.

Step therapy requires trying cheaper medications before approving expensive ones. For example, metformin before GLP-1 drugs, or generic statins before PCSK9 inhibitors.

You can skip step therapy if:

• You've already tried and failed the required medications (document this!)
• The required medication is contraindicated (allergies, interactions, medical conditions)
• Step therapy would cause serious health risks or treatment delays
• Your state has step therapy override laws (35 states have protections)

Our AI identifies step therapy completion in your medical records and generates override requests with clinical justification.

Yes, the appeal letter must come from your doctor—but we make it easy. Here's how it works:

1. We draft the letter: Our AI generates a complete appeal letter with clinical evidence, guideline citations, and medical necessity justification
2. Doctor reviews and signs: Your doctor reviews for accuracy and adds their signature (takes 5-10 minutes vs. 2 hours to write from scratch)
3. We submit everything: We handle submission, tracking, and follow-up

Doctors love this because the letter is better than what they'd write manually—it includes specialty society guidelines, peer-reviewed studies, and FDA-approved indications they might not have time to research.

Essential evidence (we help gather):

• Medical records: Diagnosis, treatment history, failed alternatives
• Doctor's letter: Medical necessity justification and clinical rationale
• Clinical guidelines: Specialty society recommendations (AACE, ADA, AHA, etc.)
• FDA approvals: For on-label uses or supported off-label indications
• Peer-reviewed studies: Evidence supporting your treatment
• Failed treatments: Documentation of medications already tried
• Comorbidities: Additional conditions making treatment medically necessary

Our AI advantage: We analyze your documents in 2 minutes and extract all relevant evidence automatically. Manual review would take 8+ hours.

Internal review (first appeal): Your insurance company reviews the denial internally. They must decide within 30 days (or 72 hours for urgent appeals). Success rate: 39%.

External review (second appeal): An independent third party (not employed by your insurer) reviews the case. Must be requested within 4 months of internal denial. Success rate: 52%.

Key difference: External review is done by independent medical experts, not the insurer's staff. It's your best chance if the internal appeal fails.

For urgent appeals: You can skip internal review and go straight to external review if there's a serious health risk.

Free case evaluation: Upload your denial letter for instant AI analysis and success probability.

Full appeal service: $199 flat fee (or 2% of annual medication cost, whichever is less). Includes:

• AI evidence extraction from your medical records
• Doctor appeal letter drafting
• Submission and tracking
• Follow-up and escalation to external review if needed
• State insurance department complaint filing (if applicable)

Success-based pricing: Pay nothing if your appeal is denied at all levels.

Average value recovered: $12,000 per year in medication coverage. ROI: 60x.

Yes, and this is often a weak denial reason that can be successfully appealed. Here's why:

• FDA approval matters: If the drug is FDA-approved for your condition, it's not experimental
• Off-label use: Supported off-label uses (backed by clinical evidence) are standard of care, not experimental
• Clinical guidelines: If specialty societies recommend the treatment, it's established medicine
• Peer-reviewed studies: Published research demonstrates safety and efficacy

Example: GLP-1 drugs are often denied as "experimental for weight loss"—but Wegovy is FDA-approved for obesity, and clinical guidelines from AACE/ADA support use for patients with BMI ≥27 + comorbidities.

Repeated denials or pattern denials may be illegal. You have additional options:

• State insurance department complaint: Report the insurer for bad faith practices (we help file this automatically)
• Federal complaint: File with CMS (Medicare/Medicaid) or Department of Labor (employer insurance)
• Legal action: Some states allow lawsuits for repeated bad faith denials
• Switch insurance: During open enrollment, choose a plan with better coverage
• Out-of-pocket + reimbursement: Pay cash (often with manufacturer coupons) and sue for reimbursement

We track: If your insurer has a pattern of illegal denials, we escalate automatically and can connect you with legal assistance.

It depends on your insurance type:

• Commercial insurance: Yes! Manufacturer coupons can reduce out-of-pocket costs to $0-25/month even without prior authorization. Examples: Ozempic savings card, Wegovy savings card
• Medicare/Medicaid: No. Federal law prohibits manufacturer coupons for government insurance
• High-deductible plans: Coupons may not count toward deductible, so appeal is still valuable

Strategy: Use manufacturer coupons as a temporary solution while we appeal for full coverage. This prevents treatment gaps and maintains continuity of care.

Long-term: Coverage approval is better because coupons expire, have annual caps, and don't count toward out-of-pocket maximums.

The harsh reality:

• Only 0.2% of denied patients ever appeal
• Internal appeals: ~39% success rate industry average
• External review: ~52% success rate (much better!)

Why fighting back matters:

• Your odds improve by orders of magnitude just by appealing
• Most denials are rubber-stamped—a proper appeal forces actual review
• External reviewers are independent—they don't work for your insurer
• Administrative errors (wrong codes, missing docs) are almost always fixable

Our advantage: AI-powered evidence extraction finds clinical justifications human reviewers miss. We cite clinical guidelines, FDA approvals, and peer-reviewed studies that manual appeals often omit. Plus, we integrate with State Insurance Commissioners in all 50 states to escalate when needed.