Denial Appeal Letter Template for Medical Benefit

[Your Full Name] [Your Street Address] [City, State ZIP] [Phone Number] [Email Address] [Date] Appeals Department [Insurance Company / Health Plan Name] [Plans Address] [City, State ZIP] Re: Appeal of Denial Policy #_________ Claim #: ___________ Date of Denial: ___________ Reference No.: ___________ Dear Appeals Reviewer, I am writing to formally appeal the denial of coverage for [Name of Service/Procedure/Medication] rendered on [Date of Service] for [Patients Name if different from the subscriber]. The denial letter dated [Denial Date] cites [Reason Stated in Denial (e.g., experimental, not medically necessary, outofnetwork)]. After careful review of my medical records and the applicable plan documents, I believe this decision is erroneous and request that the claim be approved. 1. **Medical Necessity** [Patients Name] has been diagnosed with [Diagnosis Code(s) and Description], which, according to the latest clinical guidelines (cite guideline, e.g., American Heart Association 2023), requires [specific service] to prevent serious health deterioration. My treating physician, Dr. [Physician Name] (MD, Specialty), has documented the following supporting evidence: - [Test Result #1] shows [relevant finding]. - [Test Result #2] indicates [relevant finding]. - Prior attempts at [alternative treatment] have been unsuccessful, as evidenced by [summary of attempts]. 2. **Plan Language Supporting Coverage** Section ___ of the [Plan Name] EvidenceBased Coverage Policy states: Service X is covered when medically necessary for condition Y. The enclosed excerpt (see Attachment A) confirms that my condition meets this criterion. 3. **Regulatory Requirements** Under [Applicable Law or Regulation, e.g., ACA Section 2719, NY State Insurance Law 3685], the insurer must provide coverage for medically necessary services based on accepted standards of care. The denial conflicts with these obligations. 4. **Attached Documentation** - Physicians letter of medical necessity (Attachment B) - Full medical records, including lab and imaging reports (Attachment C) - Relevant peerreviewed articles supporting the efficacy of the service (Attachment D) - Copy of the plans coverage policy excerpt (Attachment A) **Requested Action** In light of the above, I respectfully request that the denial be reversed and that payment be authorized for the service rendered. Please confirm receipt of this appeal and provide a written decision within 15 business days, as required by the plans appeals timeline. Thank you for your prompt attention to this matter. I am available for any further clarification and can be reached at the phone number or email listed above. Sincerely, _________________________ [Your Signature] [Printed Name] [Relationship to Patient, if applicable] [Policy Number]