Appeal Letter to Health Plan Option a Medical Necessity

Sample appeal letter medical necessity denial—Option A

[Date]

Attn:______

Provider Appeals Department

[Address]

[City, State, ZIP Code]

Re: Medical necessity denial

Insured/Plan Member:______

Health Insurer Identification Number:______

Group Number:______

Patient Name:______

Claim Number:______

Claim Date:______

Dear [Health insurer]:

This letter confirms our conversation today about the care of [patient name] and requests a review of this clinically inappropriate denial. As a physician, I have an ethical and legal duty to advocate for any care I believe will materially benefit my patients. As you will recall, I recommended [describe procedure, course of treatment referral etc.], which I believe is medically necessary for the following reasons: [reason procedure or service was performed].

[Health insurer] has made a decision to deny this care. I will inform the patient in writing of this decision, including alternative treatment options: [list alternative treatment options]. In addition, I will include this letter as part of the patient’s medical record.

If this is not accurate, please advise me promptly. Again, I believe this [procedure, test, course of treatment] is medically necessary. In my clinical judgment, [health insurer]’s denial of coverage is not in the best interest of the patient.

In the event that [patient name], the family, or employer wish to hear your reasoning, I will refer them directly to you to avoid any misrepresentation.

Sincerely,

[Physician]