Appealing Insurance Denials for Therapy and Equipment: A Parent’s Step-by-Step Guide

An insurance denial for your child’s physical therapy, wheelchair, or assistive device can feel like a brick wall. But the denial letter is not the final word; it’s the beginning of a process. The majority of well-documented appeals succeed. This guide walks you through exactly how to build and submit an appeal that gives you the best chance of reversal.

Why Insurance Denials Happen, and Why They Often Can Be Reversed

Insurance companies deny therapy and equipment claims for several predictable reasons:

• Medical necessity not established: The claim didn’t include sufficient clinical documentation
• Missing prior authorization: The service wasn’t pre-approved before it began
• Coding errors: A wrong diagnosis or procedure code on the claim form
• Frequency or duration limits: The plan limits the number of therapy visits per year
• Coverage exclusions: The plan categorizes the service as ‘not covered’ or ‘experimental’
• Maintenance therapy denial: Insurers frequently deny therapy for children with ‘static’ conditions, arguing that ongoing therapy only ‘maintains’ function, which directly contradicts the evidence base for cerebral palsy treatment

Many denials, particularly for children with documented progressive functional needs, are overturned on appeal when the right documentation is submitted. You have both the right and the tools to fight this.

Step 1: Read the Denial Letter Carefully

The denial letter is your roadmap. Extract:

• The exact reason for denial; get the specific language, not just the summary
• The claim number and date of service
• The appeal deadline, typically 30 to 180 days; missing this is catastrophic
• Whether an internal appeal is required before external review
• The address or portal where the appeal must be submitted
• Whether the plan requires specific forms

File the denial letter in your medical binder immediately. Every subsequent document goes on top of it.

Step 2: Gather Your Documentation

A strong appeal includes:

• Letter of medical necessity from the prescribing physician: This is the single most important document. It should explain the diagnosis, the functional limitations, why this specific therapy or equipment is medically necessary, what will happen without it (deterioration, safety risk, hospitalization), and how it differs from a ‘maintenance’ or ‘convenience’ service.
• Therapy evaluation reports: Formal assessments documenting baseline function, standardized test scores, and measurable deficits.
• Progress notes showing functional change: Evidence that the child responds to therapy, not ‘static.’
• Relevant clinical guidelines: APTA, AOTA, ACMG, or AAP practice guidelines supporting the treatment. These counter ‘experimental’ and ‘not medically necessary’ denials.
• Peer-reviewed research: One or two relevant studies showing clinical benefit for children with cerebral palsy.
• Your child’s medical records linking the diagnosis to the need.

Step 3: Write a Clear Appeal Letter

Your appeal letter should be professional, factual, and specific. Include:

1. Your child’s name, date of birth, member ID, and claim number
2. A clear statement that you are appealing the denial of [service] on [date] for reason [stated in denial letter]
3. A brief summary of your child’s diagnosis and functional limitations
4. A clear rebuttal of the specific denial reason: ‘The denial cites lack of medical necessity. Enclosed is a letter of medical necessity from Dr. [name] explaining…’
5. A list of all attached supporting documents
6. A request for the medical criteria used to evaluate the claim
7. Your contact information and signature

Step 4: Submit Before the Deadline

• Send by certified mail with return receipt, or via the insurer’s portal with confirmation.
• Keep a copy of every document you submit.
• Confirm receipt; call the insurer if you haven’t heard within 5 business days.
• Note the decision deadline; under the ACA, internal appeals must be decided within 30 to 60 days (non-urgent) or 72 hours (urgent/concurrent care).

Step 5: If the Internal Appeal Is Denied

You have additional options:

• External review: Under the ACA, you have the right to an independent external review if the internal appeal is denied. An independent physician reviewer, not employed by your insurer, evaluates the case. External review decisions are binding on the insurer.
• State insurance commissioner complaint: File a complaint with your state’s department of insurance if you believe the denial was improper.
• State Medicaid advocates: If your child has Medicaid, a patient advocate or disability rights attorney can help.
• Provider support: Ask your child’s therapist or physician to call the insurer directly; peer-to-peer review can sometimes reverse denials quickly.

Frequently Asked Questions

How do I appeal an insurance denial for therapy or equipment?

Request the denial in writing, note the appeal deadline, gather a physician letter of medical necessity and supporting therapy documentation, write a clear appeal letter addressing the stated reason for the denial, and submit everything before the deadline via certified mail or the insurer portal.

What is a letter of medical necessity?

A formal letter from your child’s physician or therapist explaining why a specific treatment or piece of equipment is medically required, not elective, not convenience, and not maintenance. It should reference the diagnosis, functional limitations, risks of non-treatment, and clinical evidence. This letter is the most important piece of an appeal.

What happens if my appeal is denied again?

Request an external review by an independent reviewer. Under federal law, this is your right for most employer-sponsored plans. External reviewers are not employed by the insurer, and their decisions are binding. Many appeals that fail internally succeed at external review.

What evidence is most helpful in an insurance appeal?

A detailed physician letter of medical necessity, therapy evaluation reports with standardized scores, progress notes showing functional response to treatment, peer-reviewed clinical guidelines, and specific medical literature for your child’s diagnosis are the strongest components.

📞 FREE CASE REVIEW: If insurance is denying care your child needs, you’re not alone, and you’re not out of options. We can also help you understand whether a birth injury settlement may help fund long-term care needs. Free consultation available.