Medical necessity denial appeal letter

Template

{{MEMBER_NAME}}
{{MEMBER_ADDRESS}}
{{MEMBER_PHONE}}
Member ID: {{MEMBER_ID}}
Claim / Reference #: {{CLAIM_NUMBER}}
Date of Service: {{DATE_OF_SERVICE}}
Date of Denial Notice: {{DENIAL_DATE}}

{{INSURER_NAME}}
Appeals and Grievances Department
{{INSURER_APPEAL_ADDRESS}}

Re: Formal Internal Appeal — {{CLAIM_NUMBER}}

I am formally appealing the denial dated {{DENIAL_DATE}} for {{SERVICE_OR_DRUG}}. Your notice stated the service was "not medically necessary." I disagree, and this appeal explains why the service meets the medical necessity criteria in my plan.

1. My treating physician, {{TREATING_PROVIDER}}, has submitted the attached Letter of Medical Necessity documenting (a) my diagnosis of {{DIAGNOSIS_ICD10}}, (b) the failure or contraindication of the covered alternatives your policy typically requires, and (c) why {{SERVICE_OR_DRUG}} is the appropriate next step.

2. Your denial appears to rely on {{GUIDELINE_CITED}}. Under that guideline, coverage is appropriate when {{GUIDELINE_CRITERIA}}, and the attached records show each element is met.

3. Under 29 CFR 2560.503-1(h)(2)(iii) and 45 CFR 147.136(b)(2)(ii)(C)(1), I am requesting, at no cost:
   • A copy of the complete claim file, including all guidelines, criteria, and clinical rationale relied upon;
   • The name and credentials of the reviewing physician;
   • Any expert reports generated during the review.

Please overturn the denial and authorize/pay for {{SERVICE_OR_DRUG}}. If the denial is upheld, please provide the written adverse benefit determination and clear instructions for the next level of review, including external review.

Sincerely,
{{MEMBER_NAME}}
Enclosures: Denial notice, Letter of Medical Necessity, clinical records, authorization to disclose PHI.

Key points before you send it

• Attach a Letter of Medical Necessity from the treating physician.
• Cite the specific guideline the insurer used (MCG, InterQual, plan medical policy) and rebut it.
• Request the full claim file under 29 CFR 2560.503-1(h)(2)(iii).