Sample Appeal Letter (Page 3 of 6) in pdf

Sample Patient Appeal Letter

Please note, this is NOT a form letter and should be customized for your specific

situation. You can use the suggestions in the brackets as a guide. If your physician is

also submitting a letter on your behalf, you’ll want to ensure the information in your

letter also aligns. See more helpful tips in the “Denials and Appeals” resource.

[Date]

[Name]

[Insurance Company Name]

[Address]

[City, State ZIP]

Re: [Your Name]

[Your 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],

I [or my loved one] recently 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

i.e., not medically necessary, experimental, etc.]

[I or my loved one’s name] have been under care for Type One Diabetes [T1D] since

[date]. Since that time, [I or my loved one] has [include a brief overview of patient’s

treatments and T1D management protocol i.e., 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 support your request along with

any peer-reviewed information,

this]. The service denied is critical in managing

[my or my loved one’s] condition and access to this treatment will help improve [my

or my loved one’s] health outcomes by making it easier for [me or my loved one’s] 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

Sample Appeal Letter Page 3