How to appeal a denied claim for ongoing treatment.
When the same infusion, DME, or prescription keeps coming back denied, an appeal letter is built around the next denial — not the first. The right statute is one of two: the ERISA § 503 full-and-fair-review procedure for self-funded group plans, or the ACA marketplace internal-appeal and four-month external-review path under 45 C.F.R. § 147.136. The path that applies depends on which plan you have.
01 · What this segment looks like
A repeat-denial pattern — and the appeal pathways that apply to it.
The repeat-denial segment captures patients whose chronic-condition treatment is already established and documented — they are not asking the insurer to evaluate a novel therapy, they are asking the insurer to keep authorizing a service or drug the patient has been on for months or years. The denial cycle on these cases shares a recognisable shape: a denial letter arrives at a planned re-authorization window, the appeal re-establishes the medical necessity, the insurer approves, and the same denial shape arrives again at the next cycle.
The appeal pathways that apply break cleanly along the plan’s regulatory framing. Self-funded ERISA plansare governed by the Department of Labor’s claims-procedure regulation at 29 C.F.R. § 2560.503-1 — full and fair review under § 503 of ERISA, the right to the claims file under (m), the requirement that the plan name its clinical experts under (j)(4), and the pre-service urgent-claim timeframe under (f)(2). ACA marketplace plans pick up the appeals regime at 45 C.F.R. § 147.136: internal appeal under (b)(2), the four-month external review window under (d), expedited review for ongoing care, and the Nondiscrimination obligation on clinical criteria.
A well-built second-stage appeal letter cites the right framework, ties the clinical record to the denial reason on the latest letter, and puts the external-review or civil-action follow-up on the record so the insurer sees the trajectory the case will follow if the denial is not overturned.
The three repeat-denial shapes we see most
- 01
Continuing infusions
Oncology maintenance infusions (every-3-week regimens), MS and RA biologics on quarterly schedules, IBD infusions that the insurer has historically authorized — then re-denies mid-plan-year with a fresh “medical necessity not established” rationale. The denial letter cites the same procedure code each time; the clinical context has not changed.
- 02
Durable medical equipment on replacement cycles
CPAP supplies on the standard ninety-day replacement cadence, oxygen concentrators on the rental-to-purchase conversion, mobility DME on the five-year replacement clock, prosthetics on a documented wear cycle, insulin pumps and CGM sensors on the manufacturer replacement schedule. DME denials tend to repeat because the plan resets its authorization window annually and treats each cycle as a new request.
- 03
Formulary step-therapy demands
Annual re-prior-authorizations on the same drug the patient has already failed the plan’s preferred alternative on, fail-first protocols that ignore documented prior failure on the same drug class, and formulary exclusions introduced mid-plan-year. The denial letter may not even mention the prior treatment history — the appeal has to re-establish it on every cycle.
02 · Frequently asked
The timelines and review rights that apply on a repeat denial.
Three questions a member typically has before drafting a second-stage appeal — with the specific federal regulation and the right of review attached to each answer.
03 · Submit the latest denial letter
The next denial is the one the appeal is built around.
Upload the most recent denial letter or EOB, answer the four short intake questions, and Denvowpicks the ERISA § 503 procedure or the ACA § 147.136 framing that matches your plan — and the letter branches on whether you’re at the first-stage internal appeal or the second-stage external review.
Already in the intake? Pick “second-stage” on the appeal dropdown so the letter opens with the external-review or IRO framing.
Denvow is template-and-tooling, not legal counsel. For denials that genuinely need litigation, an ERISA fiduciary complaint, or a state-court remedy, we recommend a licensed attorney in the relevant jurisdiction — and will say so when we see one.