OBJECTIVES: Formal systems of health technology appraisal (HTA) can directly inform resource allocation in healthcare systems and have contributed to the equitable and efficient allocation of such resources. To engender and maintain support from a wide range of stakeholders it is important that HTA systems are seen a socially just, particularly in the face of contentious decisions. Effective appeals processes, internal or judicial, can have an important role in meeting this goal, enabling stakeholders to directly question the evidence considered, its interpretation, and the decision making process. We conducted an empirical review of the results of all appeals made to the National Institute for Clinical Excellence (NICE) between the years 2000 and 2010, and consider whether NICE fulfills these requirements. METHODS: A retrospective review of all completed NICE technology appraisals published between March 2000 and October 2010 was conducted. Each technology appraisal was investigated for appeals. Published appeals were then categorized by appeal substance, stakeholder, and outcome. The results were presented as absolute numbers and proportions of overall responses. RESULTS: In this study 29% of appraisals resulted in a published appeal of which 41% were upheld. The most common ground for an appeal, 59% of total, was perversity of the decision, the main substance for those appeals was misinterpretation of the clinical or cost-effectiveness evidence.  By proportion of appeals upheld the most successful appeal point was that the HTA did not meet the scope or was deemed to be inequitable. Appeals involving a professional body or patient group were also more likely to be successful. CONCLUSIONS: Examination of appeals to NICE would suggest that a socially just and effective appeals process is in place. Decisions are reversible and transparent and stakeholders can both participate in and question the decision process.