Appeal Letter Sample printable pdf download

Appeal Letter Sample

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)

Appeal Letter Sample