Medical Appeal Letter Sample printable pdf download

Sample Medi-Cal Appeal Letter For Speech Denial & Referral to School District

Via Certified Mail

<Date>

Attn: Appeals and Grievances

Re: Request for Appeal for Medi-Cal Patient <Child’s name>

To Whom It May Concern:

I am writing on behalf of my child NAME (DOB: XX/XX/XXXX, Health Plan # XXXXXXXX). I am

writing to appeal/grieve about the denial letter dated (xx/xx/xxxx) that I received from (Name of

Medical Group or Health Plan) (see attached) regarding speech therapy <services>

<evaluation.> The letter states that <CHILD>’s request for speech therapy should be referred to

the school district, as is their policy for all children over age three.

I have reviewed my Evidence of Coverage Manual, on pages < xxx> it explicitly describes

speech therapy for those under age 21 as a COVERED BENEFIT as long as it is medically

necessary (include only if it says this). <CHILD’s> pediatrician, Dr XXXXX, requested the

authorization. (if an evaluation has been done): Dr XXX, along with evaluating speech therapist

XXXXX, agree that at least XX individual sessions of (specify duration, e.g 1 hour, 30 minutes)

and XX group sessions per week are medically necessary treatment for <CHILD’s> autistic

disorder.

Whether <CHILD> is attending public school or receiving an IEP is irrelevant to his/her medical

needs. California Health & Safety Code, 1374.72, states that health plans must provide

medically necessary treatment of severe mental illnesses, including autism spectrum disorder,

under the same terms and conditions applied to other medical conditions. The law does not

state that IEP services should be factored into the equation, nor does it state that children can

only get part of what was prescribed in the treatment plan because the school should be paying

for the other half.

Federal EPSDT standards require that children receive coverage of “necessary health care,

diagnostic services, treatment, and other measures . . . to correct or ameliorate defects and

physical and mental illnesses and conditions.” (42 USC Sec. 1396d(r)(5)). EPSDT medical

necessity standard assures a level of coverage sufficient not only to treat an already-existing

illness or injury but also to prevent the development or worsening of conditions, illnesses, and

disabilities (42 USC Sec. 1396d(r)(5)).

Medi-Cal managed care plans are also governed by the Knox Keene Act, and must meet the

requirement to provide “Basic Health Care Services” as described in Health & Safety code

Medical Appeal Letter Sample