Medically reviewed by Dr. Frangos, MD — board-certified physician with experience in hormone optimization and insurance access support
Last updated: March 2026
Insurance denials are common—but they are often not final. Data shows that properly documented appeals succeed at high rates (often 80%+ when fully pursued). The biggest issue is not denial—it’s that most patients never take the next step.
A patient gets denied.
They assume:
“That’s it.”
But the data says something very different.
Most denials are not the end—they’re the start of a process most people never finish.
How common are insurance denials?
Denials happen more often than most patients expect.
Data from KFF and CMS shows:
| Metric | Data |
|---|---|
| ACA marketplace denial rate | ~17% |
| Medicare Advantage denial rate | ~6–15% |
| UnitedHealthcare MA denial | ~12.8% |
| Aetna MA denial | ~14.4% |
| Patients denied recommended care | ~17% |
| Patients who don’t appeal | 50%+ |
👉 The key issue isn’t denial rates
👉 It’s that most patients never challenge them
If you’re dealing with a denial, this insurance appeal guide explains what to do next.
What happens when patients actually appeal?
This is where things change.
Data consistently shows high success rates—when the process is followed fully.
| Appeal type | Typical success rate |
|---|---|
| Internal appeal | 50–65% |
| Peer-to-peer review | 65–80% |
| External review | ~40–60% |
| All steps combined | 80%+ |
👉 A first denial is not a final decision
👉 Each step increases your chances
Why most patients never appeal
There’s a big gap between success rates and actual action.
Common reasons:
-
- they think denial is final
- the process feels overwhelming
- providers may not handle appeals directly
- they don’t know about peer-to-peer review
- they don’t know external review exists
👉 Access is not just medical—it’s administrative
Patients with guidance are far more likely to succeed.
Denial rates by medication type
Not all medications are treated the same.
Here’s what typically happens:
| Medication category | Denial pattern |
|---|---|
| GLP-1 weight loss meds | High denial, often due to exclusions |
| GLP-1 (cardio use) | Lower denial when properly documented |
| Testosterone therapy | Often denied due to missing labs/docs |
| Estradiol (HRT) | Denials tied to coding or PA issues |
| Compounded meds | Rarely covered |
👉 In most cases, documentation—not eligibility—is the issue
If you’re dealing with testosterone, this PA checklist helps avoid common gaps.
What improves approval rates the most
Not all submissions are equal.
Higher approval rates usually depend on:
-
- complete lab documentation
- correct ICD-10 codes
- clear medical necessity
- matching formulary requirements
- proper prior authorization submission
👉 Most denials happen because something is missing—not because coverage is impossible
Denial is just one part of the process
If your request is denied, you still have multiple options:
-
- Peer-to-peer review → provider discusses case with insurer
- Formulary exception → request coverage outside standard list
- Step therapy waiver → bypass required medications when appropriate
- External review → independent third-party decision
- Manufacturer programs → cost support options
- State complaint → regulatory escalation
👉 The system is layered—appeals are just one part
What the data actually tells you
The numbers point to one thing:
-
- Denials are common
- Approvals are still possible
- Most patients stop too early
👉 The outcome often depends on whether the process is completed—not just started
A simple way to approach a denial
If you’ve been denied:
-
- confirm the denial reason
- check for missing documentation
- ask about peer-to-peer review
- consider resubmission or appeal
- understand your escalation options
👉 The first denial is usually not the full story
Notes
This is where most people give up.
They see a denial and assume it’s final.
But the data shows the opposite.
Most denials can be overturned—if the process is followed all the way through.
The difference is not eligibility.
It’s whether the next step is taken.
Where Amazing Meds fits in
Amazing Meds helps with the administrative side of access:
-
- reviewing denial reasons
- organizing documentation
- guiding appeal and escalation steps
- helping navigate the full process
Clinical decisions stay with the provider.
But the process around it is where most patients get stuck.
If you’re looking to get started:
👉 See if you qualify
FAQ
What is the average insurance denial rate?
Around 17% for ACA plans and 6–15% for Medicare Advantage.
Are insurance appeals successful?
Yes. Over 80% can be overturned when fully pursued.
What causes most denials?
Incomplete documentation, incorrect coding, or missing requirements.
How long does an appeal take?
Usually 30–60 days, or faster if expedited.
Can doctors reverse denials?
Yes. Peer-to-peer review is one of the most effective ways to resolve denials early.