What to Do When Insurance Says “No”

Always remember this first:

When you are dealing with an insurance company, you are the client.
They work for you.
They have a responsibility to service your plan and respond to your requests.

This matters because insurance companies will often respond more urgently and directly to you, the policyholder, than to a third-party provider.

Your voice carries weight.

So when a denial arrives, pause—and remember: this is not the end of the road.

You Submitted the Request… and Got a Denial

You submitted the request for ABA therapy.
You followed the steps.
You waited.

And then the letter arrived.

Denied.

That word feels final—but it isn’t.

Here is the most important thing to understand:

This “no” is not infinite.
It usually means “no right now.”

A denial is information.
And information gives you options.

First: Understand What the Denial Is (and Is Not)

A denial does not usually mean:

• Your child doesn’t need services
• ABA will never be covered
• You did something wrong

It usually means:

• Documentation didn’t fully meet criteria
• Medical necessity wasn’t clearly stated
• The evaluator was not an approved provider type
• Insurance guidelines were applied narrowly

Before reacting emotionally, read the reason for denial carefully.
That reason tells you exactly how to respond.

Your Options After a Denial

Option 1: File an Appeal (Very Common, Often Successful)

Many ABA denials are overturned on appeal—especially when the request is clarified and resubmitted correctly.

An appeal is not a complaint.
It is a clinical and administrative correction.

Option 2: Fix the Documentation and Re-Submit

Sometimes the fastest path forward is not fighting the decision, but rebuilding the request with stronger documentation.

This may include:

• Updating the Comprehensive Diagnostic Evaluation (CDE)
• Adding a physician or psychologist letter
• Clarifying functional impact or safety concerns
• Including school or adaptive functioning reports

Option 3: Confirm the Provider Type Was Acceptable

Insurance companies are strict about who can diagnose and recommend ABA.

A denial may simply mean the evaluation came from a provider type the plan does not accept.

This is not about pushing harder—it’s about using the correct pathway.

Option 4: Request a Peer-to-Peer Review

In some cases, your provider can request a peer-to-peer review, where:

• A clinician speaks directly with the insurance medical reviewer
• Clinical reasoning is explained verbally
• Misinterpretations can be corrected quickly

Option 5: Use the Waiting Time Strategically

While appeals or resubmissions are pending, families can:

• Activate school-based supports
• Begin parent training or coaching
• Focus on routines and skill-building at home
• Use short-term private services if feasible

Waiting does not mean doing nothing.

A Tool You Can Use Immediately: Sample Appeal Letter

Below is a sample appeal letter framework you can copy, adapt, and submit directly to your insurance company.
This is written in professional, clinical language, because that is what insurance reviewers respond to.

Sample Appeal Letter for ABA Therapy Denial

[Parent/Guardian Name]
[Address]
[City, State, ZIP]
[Phone Number]
[Email Address]

Date: [MM/DD/YYYY]

To:
Utilization Review Department
[Insurance Company Name]
[Fax Number / Mailing Address]

Re: Appeal of Denial for Applied Behavior Analysis (ABA) Therapy
Member Name: [Child’s Full Name]
Date of Birth: [DOB]
Member ID: [Insurance ID Number]
Reference / Claim Number: [If available]

Introduction

I am writing to formally appeal the denial dated [date of denial] for Applied Behavior Analysis (ABA) therapy services for my child, [child’s name].

This appeal is submitted within the required timeframe and includes clarification and supporting documentation to address the reason(s) cited in the denial.

Diagnosis and Clinical Background

[Child’s name] has been diagnosed with Autism Spectrum Disorder (ASD) as documented in the attached Comprehensive Diagnostic Evaluation (CDE) completed by [provider name and credentials] on [date].

The evaluation documents:

• Significant functional impairments
• Delays in communication, social interaction, and/or adaptive skills
• Behavioral challenges that interfere with daily functioning and safety

These findings meet criteria for medically necessary treatment.

Medical Necessity for ABA Therapy

ABA therapy is medically necessary for [child’s name] due to:

• Clinically significant deficits requiring structured, evidence-based intervention
• The inability of less intensive services to adequately address current needs
• The impact of symptoms on daily functioning across settings

Without ABA therapy, [child’s name] is at risk for continued developmental delays and reduced functional independence.

Response to the Reason for Denial

The denial letter dated [date] cited the following reason(s):

[Briefly restate the insurance company’s stated reason for denial]

We respectfully submit that this determination was based on [incomplete documentation / misinterpretation / provider clarification needed], which is addressed in the enclosed materials.

Attached documentation includes:

• [Updated or clarified CDE]
• [Letter of medical necessity]
• [Supporting clinical or school documentation]

Request for Reconsideration

Based on the clinical evidence provided, I respectfully request reconsideration and approval of ABA therapy services for [child’s name].

If necessary, I also request the opportunity for a peer-to-peer clinical review.

Closing

Thank you for your time and consideration. Please contact me at [phone/email] if additional information is required.

Timely access to services is critical for [child’s name]’s developmental progress.

Sincerely,
[Parent/Guardian Name]

What Not to Do After a Denial

• Do not assume the answer will always be no
• Do not stop asking questions
• Do not take it personally
• Do not let a form letter silence you

Denials are part of the process—not proof you should quit.

How Kid Care Connect Supports Families After a Denial

Kid Care Connect exists for this exact moment.

We help families:

• Interpret denial letters
• Decide the most effective next step
• Prepare appeals strategically
• Communicate confidently with insurance
• Maintain momentum without burnout

Because a denial should not erase months of effort.

The Bottom Line

An insurance denial is not the end.

It’s a pause.
It’s a request for clarification.
It’s a system asking for more information.

And as the client, you have the right to ask for reconsideration.

“No” today does not mean “never.”

And you do not have to navigate this alone.