Sample Appeal Letter Template printable pdf download

Sample Appeal Letter Template

Sample Appeal Letter A

(Date)

(Name)

(Insurance Company Name)

(Address)

(City, State ZIP)

Re: (Patient's Name)

(Type of Coverage)

(Group number/Policy number)

Dear (Name of contact person at insurance company),

Please accept this letter as (patient's name) appeal to (insurance company name) decision to deny

coverage for (state the name of the specific procedure denied). It is my understanding based on your

letter of denial dated (insert date) that this procedure has been denied because:

(Quote the specific reason for the denial stated in denial letter)

As you know, (patient's name) was diagnosed with (disease) on (date). Currently Dr. (name) believes

that (patient's name) will significantly benefit from (state procedure name). Please see the enclosed

letter from Dr. (name) that discusses (patient's name) medical history in more detail.

(Patient's name) believes that you did not have all the necessary information at the time of your initial

review. (Patient's name) has also included with this letter, a letter from Dr. (name) from (name of

treating facility). Dr. (name) is a specialist in (name of specialty). (His/Her) letter discusses the procedure

in more detail. Also included are medical records, and several journal articles explaining the procedure

and the results.

Based on this information, (patient's name) is asking that you reconsider your previous decision and

allow coverage for the procedure Dr. (name) outlines in his letter. The treatment is scheduled to begin

on (date). Should you require additional information, please do not hesitate to contact (patient's name)

at (phone number). (patient's name) will look forward to hearing from you in the near future.

Sincerely,

(Your name)

Sample Appeal Letter Template