Sample Appeal Letter Template (Page 2 of 2) in pdf

Sample Appeal Letter Template Page 2

In addition to Dr. XYZ, the treating physician, the physician who referred the patient to

our practice, Dr. ABC, supported our treatment decision. His letter of support is

attached.

We believe that the service did meet your criteria for medical necessity, and is

supported by other professionals in the field, as well as the patient’s primary care

physician.

Dr. XYZ would be more than happy to schedule a conference call to discuss this

medical necessity of this case. Please contact me at 123-456-7890, if you have any

questions. I will contact you in two weeks to determine your decision.

Thank you, in advance, for your reconsideration of this situation.

Sincerely,

Betty Jones

Account Representative

cc: Guarantor (Patient)

Attachments:

• EOB, with denial highlighted

• Article [write out title and journal]

• Letter from Dr. ABC

Authors’ note: Areas in YELLOW must be customized by the practice in accordance

with the particular situation. The insurance company will state a definition of

medical necessity on its website and/or provider policy manual; use it – verbatim –

for the letter. Please note that there may be form that the insurance company requires

that may need to accompany this. Please also note that it is best to have a name to

whom to direct the appeal. If applicable, use that contact instead of “To Whom It

May Concern”. The sample appeal letter does not guarantee payment, and is offered

as a sample only.

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Sample Appeal Letter Template Page 2