What if my denial isn't a coded reason

Some denials arrive with clear codes on the Explanation of Benefits (EOB) and some arrive as a plain-English letter that says "we are not covering this." Both are workable. Here is how to translate a plain-English denial into the fields the intake form asks for.

Read the letter for four things

1. The action. Words like "not covered," "not medically necessary," "excluded under your plan," "out of network," or "prior authorization required."
2. The service or drug at issue. The name and often a CPT or HCPCS code in parentheses.
3. The date of service. Or the prescription fill date.
4. The section of the plan document they cite. This is the load-bearing part. Look for phrases like "under section 5.2 of your plan document" or "not a covered benefit under your Certificate of Coverage."

Common plain-English denials and their code equivalents

• "Not medically necessary" is usually CO-50
• "Not covered under your plan" is usually CO-96 or PR-96
• "Requires prior authorization" is usually CO-197
• "Service exceeds benefit maximum" is usually CO-119
• "Included in another service" is usually CO-97 (bundled)
• "Missing information" is usually CO-16
• "Charge exceeds allowed amount" is usually CO-45

If any of those phrases match, use the corresponding code in the intake form. The letter will read the same either way. Insurers routinely accept appeals that identify the denial by its plain-English description.

When the letter is genuinely vague

Some denials say almost nothing. "Your claim has been reviewed and denied" with no reason.

Under federal rules, that is not enough. For ERISA plans, 29 CFR 2560.503-1(g) requires the plan to give you:

• The specific reason for the denial
• Reference to the specific plan provision
• A description of any additional information needed
• A description of the plan's review procedures and time limits

For Medicare Advantage, 42 CFR 422.568 has similar requirements. For Medicaid managed care, 42 CFR 438.404 does.

If your denial letter does not include those, your appeal can include a threshold argument that the notice was defective and the plan owes you a compliant one. The intake form has a checkbox for "denial notice appears to lack required content." Use it.

What to type into the intake form

• Denial code: if you can pick a code, pick it. If not, choose "unclear" and paste the exact denial language into the narrative box.
• Narrative: paste the denial letter verbatim into the intake narrative if it fits. If it does not, paraphrase and note that you have the full letter available.
• Attach the letter: on any tier, you can upload the denial letter PDF. This is the safest option when the denial reason is ambiguous.

What if I get it wrong

If you pick the wrong code, the letter will still be a valid appeal but it may argue the wrong ground. If you notice after downloading, email support with your appeal ID and we will regenerate at no charge.

What to do next

Preview a draft at /new. If the denial reason is genuinely unclear after reading this article, upload the letter as a PDF at the top of the intake form.