How to appeal a cancer treatment denial

Step-by-step for appealing a denial of cancer treatment coverage: internal appeal, external review, peer-to-peer requests, state insurance commissioners, and common grounds for overturning denials.

Insurance denials for cancer treatment are common and often reversed on appeal. Under federal law, every health plan subject to the ACA must offer both an internal appeal process and an external review. Medicare has its own multi-level appeal structure. Self-insured employer plans are governed by ERISA and follow similar appeal rules. Denials that look final at first often are not.

This guide walks through the appeal process from first denial to external review, with specific tactics that improve the odds of overturning a denial.

The appeal process, at a glance

Request a peer-to-peer review. Your oncologist calls the insurance company’s medical director. This is often the fastest path to overturning a denial.
File an internal appeal. Written appeal to the insurance company, with supporting documentation.
Request an external review. If the internal appeal is denied, an independent third party reviews the decision.
Escalate. State insurance commissioner complaints, state attorney general, or litigation if appropriate.

Each step has deadlines. Act promptly; some deadlines are as short as 30 days from denial.

Common grounds for denial and typical rebuttals

Medical necessity

The most common denial reason. The plan asserts the treatment is not medically necessary under its criteria.

Rebuttal approach: Provide documentation showing the treatment meets generally accepted medical standards. Cite NCCN guidelines, which are the standard-of-care reference for oncology. Include peer-reviewed literature supporting the specific regimen for your specific scenario. Have your oncologist write a letter of medical necessity addressing the plan’s stated criteria directly.

Experimental or investigational

The plan asserts the treatment is experimental. This is common for novel combinations, off-label use, and some imaging.

Rebuttal approach: If the drug has FDA approval for any indication, cite the approval. If the use is off-label but supported by NCCN or published clinical evidence, cite those sources. For clinical trials, point to the ACA requirement to cover routine patient costs.

Not in-network

The plan denies coverage for out-of-network providers.

Rebuttal approach: Request an out-of-network exception based on limited in-network expertise. The case is stronger for rare cancers, specialized procedures, or when an in-network provider does not exist in a reasonable travel distance. State the specific subspecialty expertise the out-of-network provider has.

Prior authorization requirement

The plan denies because prior authorization was not obtained.

Rebuttal approach: If the treatment was truly medically necessary and obtaining prior authorization would have delayed care inappropriately, cite the plan’s emergency or urgent-care exceptions. If prior authorization was simply missed administratively, the provider’s office can often retroactively request it.

Step therapy

The plan requires trying cheaper therapies before approving the requested therapy.

Rebuttal approach: Document that the required step-therapy drugs are contraindicated, have been tried and failed, or cause unacceptable side effects. Cite literature showing the requested drug is first-line for your specific scenario.

Step 1: peer-to-peer review

Before formally appealing in writing, request a peer-to-peer review. Your oncologist calls the insurance company’s medical director (also a physician) to discuss the case. These calls often reverse denials on the spot, especially when the denial stemmed from missing clinical information rather than a judgment that the treatment is inappropriate.

The oncologist’s office typically requests the peer-to-peer review. You can call the insurance company yourself to ask that one be scheduled.

Step 2: internal appeal

File a written internal appeal with:

A copy of the denial letter
A letter of medical necessity from your oncologist addressing each reason given for denial
Supporting clinical documentation: pathology, imaging, biomarker results, treatment history
Relevant published literature or NCCN guideline citations
Your own written statement explaining the impact of the denial

Deadlines are typically 180 days from the denial for commercial plans under the ACA, and 60 days for Medicare. Insurance must respond within 30 days for prospective care or 60 days for care already received.

Step 3: external review

If the internal appeal is denied, you have the right to request an external review by an independent third party. For ACA-regulated plans, this is federal or state administered; for Medicare, there are Medicare-specific external-review procedures at the Independent Review Entity level. External review results are binding on the plan.

Request external review within the deadline specified in the internal appeal denial letter. This is typically 60 days but can be shorter; check the letter.

Step 4: escalation options

If the external review is denied, further options include:

State insurance commissioner complaint. File with your state’s department of insurance. Commissioners can order an insurer to reconsider, and often resolve disputes in the patient’s favor for egregious denials.
State attorney general. For systematic or bad-faith denial patterns.
Federal agencies. Department of Labor (for ERISA plans), CMS (for Medicare Advantage).
Legal action. A coverage attorney can pursue litigation for cases where external review has been exhausted and the denial appears improper.

Special considerations

ERISA (self-insured employer plans)

Self-insured employer plans are governed by ERISA. The appeal process is similar, but external review rights vary. ERISA preempts some state insurance laws, which can limit state-commissioner intervention.

Medicare

Medicare has a multi-level appeal structure: redetermination by the Medicare Administrative Contractor, reconsideration by a Qualified Independent Contractor, Administrative Law Judge hearing, Medicare Appeals Council review, and federal district court. Each level has specific deadlines and procedures. Medicare.gov describes the process.

Clinical trials

The ACA requires most plans to cover routine patient costs for qualifying clinical trials. Denials of clinical-trial-related coverage are often reversible by citing the ACA provision codified at 42 U.S.C. § 300gg-8.

Tactical tips

Act quickly. Every step has deadlines. Missing a deadline can forfeit the appeal.
Document everything. Written records of calls, fax receipts, certified mail confirmations. If there is a dispute later, documentation matters.
Use the cancer center’s resources. Hospital-based patient advocates and financial counselors often handle appeals. They do this routinely.
Get help. Patient Advocate Foundation (866-512-3861) provides free case management, including assistance with insurance appeals. Triage Cancer offers free legal education specifically covering insurance appeals.
Persist. Many denials are reversed at the second or third level. Do not take a first denial as the final answer.