Sample Appeal Letter (Page 5 of 6) in pdf

Sample Exception Letter

Note, your insurance company may have a standard form, which is what you should

use if it is available. This template should only be used if your insurance company

does not have a standard form to request exceptions. Make sure to check with an

insurance company representative before you begin. 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.

[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],

I am writing to request an exception that my plan cover

[medication/device/service] as it is not currently covered [for me or my loved one]

[or includes a different brand than I use] by [plan name].

I have had Type One Diabetes [T1D] since [date]. Since that time, I have [include a brief

overview of your treatments and T1D management protocol i.e., the number of finger stick

tests, insulin injections, or how frequently a pump is used, along with a brief medical history

emphasizing the most recent events that directly influence your need of the not included

medication/device/service. Incorporate any evidence of using the covered drug or

treatment as some plans may require you to have tried the covered insulin and provide

evidence that your T1D worsened under the covered brand before approving coverage for

the requested brand of insulin].

The [medication/device/service] approved by the FDA on [date] is critical in

managing my condition and access to [medication/device/service] is imperative to

manage and adhere to the recommended treatment plan. [Provide medical-based

data to illustrate how the medication/device/service is key to improving A1C levels,

hypoglycemic events, or how it helps you better manage your condition or contain

costs for more expensive alternatives. You may also consider including a peer-

Sample Appeal Letter Page 5