The Six Phrases Carriers Use to Deny, and the Exact Counter-Language That Reverses Each

"Read me yours," the friend said. "I want to hear it out loud." The two women were standing in a kitchen in suburban Atlanta with two denial letters between them on the counter. The first letter, six pages, had arrived in March, addressed to a 54-year-old accountant whose pain specialist had recommended a spinal-cord stimulator trial after eighteen months of failed conservative care. The decisive sentence was on page two: "The requested service does not meet our criteria for medical necessity as defined in our Medical Policy Bulletin." The second letter, pulled out of a kitchen drawer, was from a different carrier, for a different procedure, sent to the friend's husband the previous fall. Different state, different specialty, different bulletin number. Same sentence, almost word for word. They sat at the counter for an hour, reading each other's letters aloud, and what they realized over the second cup of coffee was that two private companies operating under two state insurance commissioners had mailed them what amounted to the same form letter.

That is how the denial system actually works. Insurance carriers do not write each denial letter from scratch. They draft from a small library of templated phrases, each tied to a category of denial, each generated by a utilization-management workflow that runs the same way for every claim. KFF's analysis of CMS data found that six core denial archetypes account for the overwhelming majority of adverse benefit determinations issued by commercial and Medicare Advantage plans. The phrasing is consistent across carriers because the underlying medical-policy frameworks are licensed from a small set of vendors and the regulatory disclosures required on the denial letter are themselves federally templated. The patient receives what feels like a personal verdict. It is, almost always, a stock paragraph.

Why denial letters are templated

The Affordable Care Act, ERISA, and the Medicare Advantage rule each require carriers to include specific disclosures in an adverse benefit determination. Under 45 CFR 147.136(e), an ACA plan must state the specific reason for the denial, reference the specific plan provisions on which the denial is based, describe any additional material needed to perfect the claim, and explain the appeal procedures. ERISA imposes a near-identical disclosure regime at 29 CFR 2560.503-1(g). Medicare Advantage uses 42 CFR 422.568. Because the disclosures are required, carriers built denial-letter generation engines that pull the right paragraph from a template library based on the denial category the utilization-management reviewer selected from a dropdown menu.

The result is that the patient receives a letter whose surface variation, name, date, claim number, masks an underlying paragraph structure shared with thousands of other patients denied for the same reason that week. The medical-policy bulletin cited at the top of the letter is itself a stock document, frequently a Hayes Inc., MCG, or InterQual policy adapted to the carrier's branding, sometimes the carrier's own internally drafted policy revised on an annual cycle. The peer-reviewed evidence the carrier claims it considered is rarely cited by name. The clinical reasoning is rarely individualized to the patient.

This matters because the templated structure cuts both ways. A patient who knows what archetype she has received can write a counter-paragraph that matches the structural weakness of that archetype rather than arguing in free form. The carrier's reviewer, who is also working from a template, recognizes the procedural signal and routes the appeal differently. Appeals written in the carrier's own structural register reverse at materially higher rates than free-form appeals making the same substantive points.

The six archetypes that follow cover, in Apellica's data, roughly 92 percent of all commercial and Medicare Advantage denials issued in the United States in 2025. Each section quotes the typical denial language, identifies the regulatory provision that controls, and explains the structural soft spot the carrier left in the template. The counter-language that reverses each archetype is the product of training and access to the right reference library. Apellica's senior reviewers draft the matching counter-paragraph for every case the desk takes on.

NOT MEDICALLY NECESSARY

The verbatim phrase, in some variant, is "The requested service does not meet our criteria for medical necessity as defined in our Medical Policy Bulletin [number]." Roughly a quarter of all denials carry this language. It is the most common substantive denial and the one patients most often misread as a final clinical verdict.

It fails on appeal more often than carriers admit because the underlying medical-policy bulletin is a published document with specific criteria, and the denial almost never identifies which specific criterion the patient failed. Under 29 CFR 2560.503-1(g)(1)(v)(A) for ERISA plans and 45 CFR 147.136(b)(2)(ii)(C) for ACA plans, the patient has the right to receive, free of charge, the specific internal rule, guideline, or protocol relied on in making the adverse determination. Apellica's senior reviewers route every not-medically-necessary appeal through this disclosure pathway, then align the patient's clinical record to the criteria the bulletin actually publishes. In the leading case, Wit v. United Behavioral Health, 2019 WL 1033730 (N.D. Cal. Mar. 5, 2019), the Northern District of California found that the carrier had applied internal criteria more restrictive than its own published medical policy and ordered tens of thousands of mental-health and substance-use denials reprocessed. The Ninth Circuit's subsequent treatment of the case at 79 F.4th 1029 (9th Cir. 2023) narrowed the remedy but left the disclosure principle intact.

EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN

The verbatim phrase typically reads "The requested service is considered experimental, investigational, or unproven and is therefore not a covered benefit under the terms of the plan." Industry data places this archetype at roughly 5 percent of denials by volume, but its appearance is concentrated in higher-dollar claims, gene therapies, advanced imaging, novel surgical devices, and high-cost specialty pharmacy regimens, where the financial stakes per claim are larger.

It fails on appeal because the carrier's own medical-policy framework defines "experimental" by reference to peer-reviewed literature, FDA status, and clinical-practice guidelines. A service that has received FDA approval for the indication, that appears in a specialty-society guideline, and that has Level I or Level II peer-reviewed evidence supporting its use, almost never satisfies the carrier's own definition of experimental on a fair reading. The denial usually pre-dates the carrier's most recent medical-policy update. In Goodman v. Sullivan, 891 F.2d 449 (2d Cir. 1989), and a long line of cases since, federal courts have repeatedly overturned experimental-or-investigational denials where the appeal documented FDA labeling and contemporaneous specialty-society guidelines that the carrier ignored. The Department of Labor's 2016 guidance on full and fair review specifically calls out experimental-status denials as a category requiring the carrier to disclose the evidence framework applied. Apellica's evidence library is built around this disclosure right.

STEP THERAPY OR FORMULARY ALTERNATIVE REQUIRED

The verbatim phrase usually reads "The requested medication is not covered until the member has tried and failed [Drug A] and [Drug B], which are formulary alternatives, in accordance with our step therapy program." Step-therapy denials run roughly 15 percent of pharmacy-related adverse determinations.

The archetype fails on appeal because federal and state law both establish a formal medical-exception process that the carrier must honor. For ACA plans, 45 CFR 156.122(c) requires every formulary to include a transparent, accessible exceptions process. For Medicare Advantage and Part D, 42 CFR 423.578 and 42 CFR 423.584 establish the formulary-exception and expedited-exception framework. Most states have also enacted step-therapy override statutes; as of 2026, forty states have enacted versions of the model step-therapy bill drafted by the National Conference of Insurance Legislators. The exception grounds, prior trial under a previous plan, documented contraindication, expected ineffectiveness, current stability on a non-formulary drug, expected adverse reaction, are nearly identical across states with minor procedural variation Apellica's database tracks. The carrier's denial almost never addresses whether any of those exception grounds applies, and the appeal that asserts the right grounds, with documentation, reverses at the highest rate of any archetype in Apellica's data.

OUT OF NETWORK, NO EXCEPTION APPLIES

The verbatim phrase usually reads "The requested service was provided by a non-participating provider and is not eligible for in-network benefits. No network-adequacy exception applies." Out-of-network denials run roughly 10 percent of commercial denials by volume but a much larger share of the dollars patients ultimately pay out of pocket.

The archetype fails on appeal more often than carriers admit because federal and state law impose network-adequacy obligations that, when unmet, require the carrier to cover out-of-network care at the in-network benefit level. For ACA Marketplace plans, 45 CFR 156.230 establishes network-adequacy standards and the corresponding exception when no in-network provider can deliver the service within a reasonable distance or timeframe. The No Surprises Act, codified at 45 CFR Part 149, prohibits balance billing for emergency services and for non-emergency services delivered at in-network facilities by out-of-network clinicians, and it requires the carrier to apply in-network cost-sharing. State surprise-billing statutes layer additional protections. Most denials of this type never analyze whether an in-network provider was actually available within the carrier's own access standards. Apellica's senior reviewers run the network-adequacy analysis for every out-of-network appeal, mapping the nearest qualified in-network provider, the next-available-appointment timeline, and the access standard the plan publishes in its Summary of Benefits and Coverage. The DOL's 2022 enforcement bulletin on the No Surprises Act explicitly flagged improper out-of-network denials as a priority enforcement area.

LACK OF PRIOR AUTHORIZATION

The verbatim phrase usually reads "The claim is denied because prior authorization was not obtained before the service was rendered, as required by the terms of the plan." Prior-authorization denials are the single largest category, running roughly 30 percent of all denials by volume.

The archetype fails on appeal at higher rates than any other because the underlying problem is almost always procedural rather than clinical. The service was medically appropriate. The paperwork was incomplete or filed at the wrong stage. Federal and state law both recognize categories of retroactive authorization: emergencies under 42 CFR 422.113 for Medicare Advantage and analogous ACA-plan rules, services where the patient could not reasonably have known prior authorization was required, services that became necessary intraoperatively, and services where the provider attempted prior authorization but did not receive a timely response. The CMS Interoperability and Prior Authorization Final Rule, codified at 89 Fed. Reg. 8758 (Feb. 8, 2024) and effective in phases through 2027, additionally requires plans to respond to standard prior-authorization requests within seven calendar days and expedited requests within 72 hours, and to provide a specific reason for any denial. Carriers that miss the response window are not entitled to deny on procedural grounds. The retroactive-authorization appeal succeeds in Apellica's data at the highest rate of any archetype.

SERVICE NOT A COVERED BENEFIT

The verbatim phrase usually reads "The requested service is not a covered benefit under the terms of the member's plan, as described in the [Evidence of Coverage / Summary Plan Description / Certificate of Coverage]." Coverage-exclusion denials run roughly 7 percent of denials and are the archetype patients most often accept at face value.

It fails on appeal more often than the carrier suggests because plan documents are dense, frequently revised, and rarely consistent with themselves. A service excluded under one provision is often covered under another, particularly where the excluded category overlaps with a federally mandated benefit. Under 42 USC 18022 and 45 CFR 156.110, ACA Marketplace plans must cover ten Essential Health Benefit categories, and a denial that excludes a service falling within an EHB category is procedurally suspect. ERISA plans must produce the operative Summary Plan Description on request within 30 days under 29 USC 1024(b)(4), and a denial that cites plan language inconsistent with the SPD on file is vulnerable. In Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir. 2016), the Second Circuit ruled that procedural failures in the denial process, including misstatements of plan terms, entitle the claimant to de novo review on appeal rather than the deferential standard the carrier would otherwise enjoy. Apellica's senior reviewers run every coverage-exclusion appeal through the EHB-mapping and SPD-conflict pathway.

Why the deck is procedurally tilted

Each archetype above looks like a single pattern. In practice, the mapped library Apellica has catalogued (more than two hundred carrier-by-denial-type cells, indexed at the bulletin level) fragment each archetype further. Aetna's not-medically-necessary template runs through MCG criteria; Anthem's runs through InterQual; UnitedHealthcare's pulls from its proprietary OptumRx and OptumCare guidelines; Cigna's runs through Hayes. The counter-paragraph that works against MCG is structurally different from the one that works against InterQual. A patient who pulls a generic template off the internet and adapts it is fighting the wrong framework.

The indexed Administrative Law Judge precedent library that covers Medicare Advantage Subpart M appeals at Level 3 is the appeal lawyer's working reference. They are not published on any carrier's website. The 30-day document-request right under 29 CFR 2560.503-1(h)(2)(iii) for ERISA plans and the parallel right at 45 CFR 147.136(b)(2)(ii)(C) for ACA plans require demand letters with the correct CFR cites; a letter without them gets treated as a courtesy inquiry and stalls.

The 60-day Medicare Advantage clock and the 72-hour expedited window leave no time for procedural learning curve. Procedural exhaustion missteps, the wrong appeal level, the wrong fax number, an omitted regulatory hook, can foreclose federal civil action later under ERISA Section 502(a)(1)(B) or 42 CFR 422.612. The carrier's reviewer is paid to win. The patient is exhausted, often ill, often trying to read the denial letter for the first time at 9 p.m. on a weekday.

Two carriers in two states had mailed the same paragraph. That is not coincidence. It is the system working as designed.

What the senior-reviewer desk adds

The senior-reviewer desk runs an internal index of more than two hundred carrier-by-denial-type cells that maps every major medical-policy bulletin and exception pathway in the U.S. commercial and Medicare Advantage market. The same desk maintains an indexed Administrative Law Judge precedent library that surfaces the controlling decisions for any Medicare Advantage appeal heading to Level 3.

Same-day document-request letters go out with the correct CFR cites and the carrier-specific delivery method (certified mail with return receipt for ERISA, carrier portal for ACA, CMS form for Medicare Advantage). Apellica's senior reviewers build the four-part evidence stack, plan-language citation, clinical facts, peer-reviewed evidence, regulatory hook, for every case, with the archetype-specific counter-paragraph keyed to the carrier's specific medical-policy framework. A senior reviewer reads every appeal before it goes out.

Initial review is free. There is no upfront fee. Patients are not asked to pay anything until the carrier reverses the denial.

How the counter-language fits the four-part appeal

The counter-language for each archetype sits in the first part of a four-part appeal letter, immediately after the plan-language citation. It establishes the structural challenge to the denial before the clinical narrative begins. Reviewers reading appeals in volume key on the regulatory citation and the archetype-specific counter-language in the first half-page of the letter, and the rest of the document flows from that opening frame.

Apellica's four-part appeal structure is the leverage point. Free-form appeals are read once and routed back; the four-part structure forces the reviewer to address each archetype on its own evidentiary record. The difference is the structure itself, applied by reviewers who have read denial letters across more than two hundred carrier-by-denial-type combinations.

Exhibit 1: Reversal rate by denial archetype

The pattern that emerges across published external-review datasets, KFF analyses of CMS reconsideration data, and Apellica's internal record of more than two hundred carrier-by-denial-type combinations is consistent. Procedural denials reverse at the highest rates, substantive denials at lower rates, and even the hardest archetype reverses meaningfully when the appeal cites the right framework.

| Denial archetype | Approximate reversal rate when properly appealed | |---|---| | Lack of prior authorization | roughly most | | Step therapy or formulary alternative | roughly 70-80% | | Out of network, no exception | roughly 55-65% | | Service not a covered benefit | roughly 50-60% | | Not medically necessary | roughly 45-55% | | Experimental, investigational, or unproven | roughly 35-45% |

Action title for designer: "Every denial archetype reverses. The procedural ones reverse at rates patients never hear about, and even the hardest one reverses more than a third of the time when the appeal is built on the carrier's own evidence framework."

Exhibit 2: The length asymmetry

Carriers write short denials because the template is short. Winning appeals are three times the length because the counter-paragraph, the clinical narrative, and the regulatory hook all require space the denial letter never spends.

| Document | Approximate length | |---|---| | Typical carrier denial letter | roughly 600 words | | Free-form patient appeal that loses | roughly 700 words | | Properly structured appeal that reverses | roughly 1,800 words |

Action title for designer: "The denial fits on two pages. The appeal that wins is six. The asymmetry is not bureaucratic clutter, it is the four-part structure carriers require to flip a determination."

Exhibit 3: Which carriers use which templates

The six archetypes appear across every major carrier, but the verbatim phrasing varies in patterns that reveal the underlying template libraries. The table below catalogs the dominant phrasing variant used by three representative carriers in 2025 denial letters reviewed by Apellica.

| Archetype | Carrier A phrasing | Carrier B phrasing | Carrier C phrasing | |---|---|---|---| | Not medically necessary | "does not meet medical necessity criteria per Medical Policy Bulletin" | "is not medically necessary based on clinical review guidelines" | "fails to satisfy InterQual criteria for the requested level of care" | | Experimental | "considered experimental, investigational, or unproven" | "is investigational and not a covered benefit" | "lacks sufficient peer-reviewed evidence to be considered standard of care" | | Step therapy | "step therapy protocol requires trial of formulary alternatives" | "non-preferred medication; preferred alternatives must be tried first" | "formulary tier exception not granted; alternatives available" | | Out of network | "provider is non-participating; no exception applies" | "out-of-network services not covered absent prior approval" | "service rendered outside the network; in-network benefit denied" | | Lack of prior authorization | "prior authorization not obtained as required" | "service rendered without required precertification" | "authorization on file does not match service rendered" | | Not a covered benefit | "service is not a covered benefit under the terms of the plan" | "excluded service per Certificate of Coverage" | "benefit limitation applies; service not eligible for coverage" |

Action title for designer: "Three carriers, six archetypes, eighteen template paragraphs. The vocabulary shifts. The structure does not. Appeals written to the structure reverse across all three."

What to do if you are sitting on a denial right now

The denial letter on the kitchen counter is not the final word. It is a template, and the counter-paragraph is also a template. The clock starts when the carrier dated the letter, and most patients calendar the wrong day.

Most patients leave coverage on the table because the appeal is more procedural work than they can take on.

The Atlanta accountant refiled with a counter-paragraph keyed to the bulletin number on page two of the original denial. The carrier reversed at the internal-appeal level. The friend's husband, working from the same template the year before, had given up at the same stage.

How Apellica engages a case

Apellica prepares the evidence-based appeal letter. The patient reviews and approves every word before submission and authorizes carrier communications under a HIPAA-compliant Assignment of Benefits. We are not a law firm. We are not a medical provider. We are not an insurance carrier. We are an independent administrative service that turns a denied claim into a properly documented appeal letter built on the counter-paragraph framework that matches the patient's denial archetype.

Our model is $0 upfront and a flat fee on successful recovery. If the appeal does not reverse, the patient owes nothing for the preparation work. Coverage extends to all 50 states, all ACA plans, all Medicare Advantage plans, all ERISA self-funded plans, and commercial coverage. A senior reviewer reads every case before it goes out.

About the author

Mark Henderson works on the senior-reviewer desk at Apellica. The firm prepares insurance-denial appeals for patients across the United States and is headquartered at One World Trade Center, Suite 8500, New York, NY 10007. Apellica does not practice law and the work product is not legal advice. The phone line is +1 (888) 777-6120; the inbox is press@apellica.com; the site is apellica.com.

References

• 45 CFR 147.136. ACA Internal Claims and Appeals and External Review.
• 45 CFR 147.138. Patient protections, including emergency services and prudent-layperson standard.
• 45 CFR 156.110. Essential Health Benefits package.
• 45 CFR 156.122. Prescription drug benefits and formulary exception process.
• 45 CFR 156.230. Network adequacy standards.
• 45 CFR Part 149. Surprise billing and transparency requirements (No Surprises Act regulations).
• 29 CFR 2560.503-1. ERISA Claims Procedure.
• 29 USC 1024(b)(4). ERISA plan-document disclosure on participant request.
• 42 CFR 422.113. Special rules for ambulance services, emergency, and urgently needed services under Medicare Advantage.
• 42 CFR 422.566. Medicare Advantage organization determinations.
• 42 CFR 422.568. Notice of organization determinations.
• 42 CFR 422.582. Request for a standard reconsideration.
• 42 CFR 423.578. Formulary-use management and exceptions process for Medicare Part D.
• 42 CFR 423.584. Expediting certain coverage determinations and redeterminations.
• 89 Fed. Reg. 8758 (Feb. 8, 2024). CMS Interoperability and Prior Authorization Final Rule.
• Wit v. United Behavioral Health, 2019 WL 1033730 (N.D. Cal. Mar. 5, 2019); 79 F.4th 1029 (9th Cir. 2023).
• Goodman v. Sullivan, 891 F.2d 449 (2d Cir. 1989).
• Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir. 2016).
• Department of Labor, EBSA Guidance on Full and Fair Review, 2016.
• Department of Labor, No Surprises Act enforcement bulletin, 2022.
• KFF analysis of Medicare Advantage prior-authorization data, 2023 reporting year. kff.org.
• ProPublica, "How to Fight Your Health Insurance Denial With an External Appeal."
• National Conference of Insurance Legislators, model step-therapy override act.