Sample Appeal Letter printable pdf download

Sample Physician Appeal Letter

Please note, this is NOT a form letter and should be customized for your patient’s

specific situation. You can use the suggestions in the brackets as a guide.

[Date]

[Name]

[Insurance Company Name]

[Address]

[City, State ZIP]

Re: [Patient's Name]

[Patient’s insurance member number]

[Group number/Policy number]

[Type of Coverage]

[Type of service denied and date of denial from EOB]

[Reason for denial from EOB]

Dear [Name of contact person at insurance company],

It is my understanding that [Patient's name] has received a denial for [name of

procedure] because it is believed that the procedure is [state specific reason for the

denial found on the EOB, e.g., not medically necessary, experimental, etc.]

[Patient's name] has been under my care since [date] for the treatment of type 1

diabetes [T1D]. Since that time, [patient’s name] has [include a brief overview of

patient’s treatments and T1D management protocol, e.g., the number of finger stick

tests, insulin injections, or how frequently a pump is used. Include a brief medical

history emphasizing the most recent events that directly influence your decision to

recommend the denied therapy along with any peer-reviewed information,

this,

that may support your request]. The service denied is critical in managing [patient’s

name]’s condition and access to this treatment will help improve [his/her] health

outcomes by making it easier for [him/her] to manage and adhere to the

recommended treatment plan.

For this reason I am writing to provide you with information regarding [name of

denied procedure]. [Give a brief, yet specific description of the procedure and why

you believe it should be approved and include a specific counter point to the reason

noted in the denial on the EOB. Include potential downside of treatment not being

covered like worsening A1C levels or additional out-of-pocket costs for more

expensive alternatives. Find more helpful pointers in the chart in the “Denials and

Appeals” resource].

Sample Appeal Letter