Appeal Letter for Services Denied As Not Medically Necessary :



This Letter should be written in The Letter-Pad of the Company.


From :

The Sender's Name,
Door Number and Street's Name,
Area Name,
City.
Postal Code : XXXXXXX
Phone Number : 0000 - 123456789
E-mail ID : sendersname@companywebsite.com


Date :


Reference :


TO :

Addressee's Name,
Designation,
The Company's Name,
Full Address with Phone Number.



Subject :


Dear ____,


I am writing to appeal [name of medical group OR health plan]'sdecision to deny authorization for [name of service, procedure OR treatment sought] for me. The [medical group OR health plan] has denied coverage for [name of service, procedure OR treatment], as not medically necessary. I believe [name of service, procedure OR treatment sought] is medically necessary to [treat or diagnose OR address] my medical condition and is covered by my health plan. [Name of medical group OR health plan] should approve [name of service, procedure OR treatment] in my case.


FAILURE TO PROVIDE IMMEDIATE TREATMENT FOR MY CONDITION INVOLVES AN IMMINENT AND SERIOUS THREAT TO MY HEALTH. I AM, THEREFORE, REQUESTING AN EXPEDITED REVIEW OF MY APPEAL. PLEASE NOTIFYME OF YOUR DECISION AS SOON AS POSSIBLE, AND NO LATER THAN THREE DAYS [or time specified in your evidence of coverage] FROM THE DATE OF MY REQUEST.


[Name of health plan] covers medically necessary services that are not specifically excluded. [Name of health plans definition of medical necessity is found on page [page #] of my [Evidence of Coverage OR Summary Plan Description]. Medical necessity is defined as:


[insert plan definition of medical necessity from your memberhandbook]


As explained below, [name of service, procedure OR treatmentsought], for addressing my condition, falls within this definition. The plan excludes treatments and procedures listed on page [page #] of my [Evidence of Coverage OR Summary PlanDescription]. [Name of service, procedure OR treatment sought]is not listed as an exclusion or limitation under my health plancoverage.


[Name of service, procedure OR treatment sought] is recommended for my condition by [name of doctor or specialist supporting your request]. Further, [the service, procedure OR treatment] is within the standards of good clinical practice. {If you are in a state that has 􀂳mandated benefit laws or laws that require plans to provide certain coverage, it can be helpful to refer to provisions that mandate coverage for the treatment or service you are seeking. The following language may be appropriate if there are mandated benefits laws that apply to your situation. The [medical group OR health plan's failure to provide [name of service, procedure OR treatment sought] also violates [California OR other] law which requires [applicable legal requirement]. (See Cal. Health & Safety Code § [code section number].)}


{In one or more paragraphs, describe your condition. Keep yourdescription brief but sufficiently detailed to include a chronology of your symptoms, and any tests and treatments you have undergone. The amount of detail you use will depend upon your specific situation. Following is a sample paragraph.}


I have [name of condition OR an undiagnosed condition] and itaffects my ability to conduct activities of daily living. I havepreviously received [types of other treatments you have tried, ordiagnostic tests you have undergone, if any] to [treat AND/ORdiagnose] my condition. However, my health problems have notbeen resolved. Without [name of procedure OR treatment], I willcontinue to experience [symptoms OR problems]. If left[untreated OR undiagnosed], my condition may require evenmore complex and costly treatment in the future.


I have included documentation of my medical condition, andinformation supporting the medical necessity of [name of serviceOR procedure], with this letter. Please let me know if anyadditional information will be helpful to my request. I can bereached at [telephone number].


Thank you for your immediate attention to this matter.


Yours Sincerely,


(The Sender's Signature)

The Sender's Name

Enc :

NOTE :


This is a typical letter. You have to add your company's name with full address. And the receiver's name and full address also should be added in the place allotted for that purpose. Without those primary details no letter carries any significance. So, you are requested to provide all those important details. Failing which the letter will make a wrong impression about your company and you among the receivers of your letters. This is the most unwanted attitude on your side in dealing with the clients who are the most valued assets of any business organisation. If necessary, leave those spaces blank.


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Appeal Letter for Services Denied As Not Medically Necessary
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