Insurance AppealBuilder™

About this tool

Insurance denials often feel final, leaving patients without treatment, tests, or medications they need. AppealBuilder simplifies the process of fighting back by guiding you through the elements of a strong, evidence-based appeal. By working with structured prompts about your medical need, prior treatment, and plan requirements, you assemble a professional appeal that speaks the insurer’s language. You receive a ready-to-send letter that improves your chances of overturning denials and gaining access to covered care.

Build a strong appeal letter in minutes

You have got more power than you might think

Free
Optional BCPA review available Use of this free tool includes the option of a review by a board-certified patient advocate at no cost. Upload your letter through PatientLead Health’s HIPAA-secure portal. Please allow up to 48 hours for turnaround.
40-60% of internal appeals succeed
~75% Medicare Advantage appeals win
<1% of denials get appealed
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Your Information

We will use this to address your letter properly

Your Contact Details

Insurance Company

Policy Details

We will include relevant state regulations in your letter

About Your Denial

Tell us what was denied and why

Found on your denial letter
Found on your denial letter or bill. Helps identify the exact service.
The code for your diagnosis, if known
Medical Necessity
“Not medically necessary”
Prior Authorization
PA not obtained or denied
Experimental
“Investigational” treatment
Out of Network
Provider not in network
Coding / Billing
Wrong code or billing error
Not Covered
Excluded from plan
Other / Unsure
Does not fit above
What does my denial language actually mean? ▼

Insurance denial letters use specific phrases that can be confusing. Understanding what they really mean helps you respond strategically:

“Not medically necessary”
This usually means the insurer criteria were not met on paper, not that the treatment is inappropriate for you. Your doctor may not have documented certain details the insurer requires, or the insurer guidelines may be stricter than current medical standards. Focus your appeal on demonstrating you meet their specific criteria.
“Experimental” or “Investigational”
This may mean the insurer internal guidelines have not been updated to reflect current medical practice. Many treatments labeled “experimental” are FDA-approved and widely used. Your appeal should cite FDA approval status, clinical guidelines, and evidence that other insurers cover this treatment.
“Prior authorization not obtained”
This is often a provider-side administrative failure, not a coverage issue. Contact your doctor office to confirm whether they submitted the prior auth request. If they did, ask for documentation. If they did not, ask them to submit a retroactive authorization request.
“Does not meet clinical criteria”
The insurer is applying a specific checklist or algorithm. Request a copy of the exact criteria they used. Your appeal should address each criterion point by point, showing how you meet the requirements or why an exception applies.
“Not a covered benefit”
Check your Summary of Benefits carefully. This phrase is sometimes used incorrectly when the real issue is medical necessity. Ask the insurer to cite the specific exclusion in your plan document. If they cannot, the denial may be invalid.
Was this denial made by AI or a computer system?
Look for phrases like “automated review,” “algorithm,” “system-generated,” or unusually fast turnaround (same day denial). If unsure, select “Maybe/Unsure.”
Yes
Maybe / Unsure
No

Medical Details

This helps demonstrate why the treatment is necessary

Your doctor can help with medical language, but your perspective matters too
This shows you have exhausted other options. Insurers often want to see this.

Strengthen Your Case

Additional details that can make your appeal more compelling

Personal stories can be powerful. Insurers are required to consider quality of life.
If this denial stands, what would you have to pay?

Supporting Research (Optional)

If you have medical studies supporting your treatment, add them here. Your doctor may be able to provide these.

Where to find supporting research ▼

You do not need a medical degree to find supporting evidence. Here are the best places to look:

  • PubMed.gov – Free database of peer-reviewed medical studies. Search for your diagnosis + treatment name. Look for “meta-analyses” or “systematic reviews” as these summarize multiple studies.
  • Your specialty society website – Medical specialty organizations publish clinical guidelines.
  • FDA.gov – For medications, search the drug name to find the approval letter and labeled indications.
  • Ask your doctor office – They may have access to medical literature you do not, and can often provide relevant studies with your appeal.

Review and Generate

Choose your letter style and review your information

Professional
Formal and factual
Assertive
Firm with regulatory citations
Personal
Emphasizes human impact

Your Information Summary

Before you generate
Make sure to gather supporting documents: your denial letter, doctor notes, test results, and any relevant medical records. These strengthen your appeal significantly.
Your progress is automatically saved in your browser

Your Appeal Letter

Review, edit if needed, then print or save

Free
Optional BCPA review available Upload your letter through PatientLead Health HIPAA-secure portal. Please allow up to 48 hours for turnaround.
Letter copied to clipboard!

What to Ask Your Doctor For

A Letter of Medical Necessity from your doctor significantly strengthens your appeal. Show template to share with your doctor office

Dear Doctor,

I am appealing an insurance denial and would appreciate a Letter of Medical Necessity to support my case. The insurer denied coverage for [treatment], stating: “[denial reason]“

The letter should ideally include:

1. My diagnosis and relevant medical history
2. Why this specific treatment is medically necessary for my condition
3. What alternative treatments have been tried and why they were inadequate
4. The expected outcome if treatment is approved vs. denied
5. Any relevant clinical guidelines or peer-reviewed research supporting this treatment
6. Your professional credentials and experience treating this condition

The letter should be on your office letterhead and include your contact information. I need to submit my appeal by [deadline].

Thank you for your support.

Ask about a peer-to-peer review

You can also ask your doctor if they are willing to request a peer-to-peer review with the insurer medical director. These direct conversations between physicians often resolve denials faster than written appeals.

Before You Send: Submission Checklist

Make copies of everything Keep copies of your letter and all attachments for your records
Attach supporting documents Include your denial letter, doctor letter of medical necessity, relevant test results, and medical records
Send via certified mail or trackable method This creates proof of delivery. Keep your tracking number.
Note your deadline Most appeals must be filed within 180 days of denial
Follow up in 30 days If you have not heard back, call to confirm receipt and check status
Show follow-up call script ▼
What to say
“Hi, I am calling to check on the status of my appeal for claim number [X], submitted on [date]. Can you confirm it was received and tell me when I can expect a decision?”
What to document: Write down the date and time of your call, the name of the person you spoke with, their employee ID if provided, and exactly what they told you.

What Happens Next?

Your insurer must respond within 30-60 days for non-urgent cases (faster for urgent care). If your internal appeal is denied, you have the right to an external review by an independent third party.

External reviews have high success rates
Studies show external reviews overturn insurer denials 40-60% of the time. For some denial types, success rates exceed 70%. This is a powerful tool you should use if your internal appeal fails.
If my internal appeal is denied, what do I do? ▼
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Step 1: Note your deadline
You typically have 4 months (120 days) from your internal appeal denial to request external review. Some states allow longer. Check your denial letter for the exact deadline.
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Step 2: Request external review
Contact your state insurance department (listed in your denial letter or below). You can also request external review through your insurer, who must forward your request. Many states offer online filing.
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Step 3: Submit additional evidence
External review is your chance to submit new information. Include any additional medical records, new test results, or updated letters from your doctor. Address any specific reasons given for the internal appeal denial.
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What makes external review different from internal appeal?
An independent reviewer (a doctor with no ties to your insurer) examines your case. They review everything fresh. If they rule in your favor, the decision is legally binding. Your insurer must cover the treatment.

How External Review Works:

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Request within 4 months
After your internal appeal is denied, you typically have 4 months to request external review. Some states allow longer.
2
Independent reviewers examine your case
A physician or medical expert who has no relationship with your insurer reviews all the evidence. Your insurer cannot influence their decision.
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Decision is binding
If the external reviewer rules in your favor, your insurer must cover the treatment. This is a legally binding decision.

Our tools are provided for self-advocacy purposes only. Results do not constitute medical advice, diagnosis, or treatment, and are not a substitute for professional medical judgment. Use of this tool does not create a client relationship with PatientLead Health LLC. PatientLead Health LLC is not responsible for any outcomes, decisions, or actions taken based on the use of this tool.

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