Sample Appeal Letter Template printable pdf download

Date

[Insurance Company’s address]

To Whom It May Concern:

Thank you for the opportunity to submit this denied claim for reconsideration of

payment. We are contacting you about the services rendered to [Details about the

patient’s name, date of service, and services rendered].

This service was denied on [Date]. The attached documentation presents the denial, as

noted on the explanation of benefits we received. A subsequent communication was

made over the telephone to [Name of Representative and Reference Code for call],

however, this letter serves to formalize our request for reconsideration of payment.

The services rendered to the patient were denied because, according to your company,

the diagnosis did not support the rendering of the service. Indeed, the service was

deemed not medically necessary for the patient. For background purposes, your

insurance company defines “medical necessity” as “… a term used to refer to a course

of treatment seen as the most helpful for the specific health symptoms you are

experiencing. The course of treatment is determined jointly by you, your health

professional and XYZ HealthCare. This course of treatment strives to provide you with

the best care in the most appropriate setting.”

The services rendered were medically necessary for this patient. The procedure notes

are attached to this letter. Dr. XYZ, the treating physician offers this statement:

[Ask that your physician dictate a professional response to the denial, addressing the

medical necessity of the service. Maintain a copy of this statement and letter, in the

event of future denials.]

As published in a peer-reviewed journal, the medical literature (which is attached)

supports the rendering of this service in the setting in which it was rendered. Indeed,

the services provided were the “course of treatment which was the most helpful for

[Patient’s Name] health symptoms” in the “most appropriate setting”.

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Sample Appeal Letter Template