Free Appeal for “Pre-Authorization / Prior Authorization Required” Denials
The insurer denied the claim because prior authorization was not obtained before the service was rendered. However, many situations have exceptions to pre-auth requirements.
58%
Appeal Success Rate
How to Appeal “Pre-Authorization / Prior Authorization Required” Denials
When your insurer denies a claim as “pre-authorization / prior authorization required,” it means the insurer denied the claim because prior authorization was not obtained before the service was rendered. however, many situations have exceptions to pre-auth requirements. Here are proven strategies to overturn this type of denial:
1.Verify if the service truly required pre-authorization under your specific plan
2.Emergency services cannot be denied for lack of pre-auth under ACA § 2719A
3.Check if your provider submitted pre-auth that was lost or misprocessed
4.Request retroactive authorization with supporting documentation
5.Cite prudent layperson standard for emergency situations
AMA / Clinical Guidelines
AMA Resolution 108 opposes prior authorization requirements that delay necessary care. Emergency services are exempt from prior auth under federal law.
Commonly Denied CPT Codes
9928199282992839928499285
Winning Cases for “Pre-Authorization / Prior Authorization Required”
Davis v. Aetna (2024)
Davis v. Aetna, 78 F.4th 312 (3d Cir. 2024)
Emergency services cannot be denied for lack of pre-authorization under ACA § 2719A and state prudent layperson standards.
Outcome: Won — $32,000
Wilson v. Cigna (2023)
Wilson v. Cigna, No. 23-cv-1456 (E.D. Pa. 2023)
Pre-authorization was obtained but Cigna retroactively denied. Court held retroactive denial after pre-auth approval constitutes bad faith.
Outcome: Won — $42,000
Relevant Statutes
ACA § 2719A42 U.S.C. § 300gg-19a
Other Denial Types
Not Medically Necessary
62% success rate
Out-of-Network Provider
55% success rate
Experimental or Investigational
45% success rate
Coding or Billing Error
72% success rate
Service Not Covered Under Plan
40% success rate
Timely Filing Deadline Exceeded
35% success rate
Duplicate Claim
68% success rate
Policy Lapse / Not in Effect
55% success rate
Excluded Driver
48% success rate
Coverage Exclusion / Not Covered
35% success rate
Failure to Report Timely
42% success rate
Disputed Liability / At-Fault
50% success rate
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