Has your health insurance denied coverage for a medical procedure or treatment that your doctor says is medically necessary?
You’re not the only one.
Insurance companies often challenge claims for surgeries, medications, therapies, and medical equipment, even when a doctor has prescribed them as essential for a patient’s health and well-being.
But you don’t have to take no for an answer.
With a strong letter of appeal, you can make a compelling case for why your insurance should cover the care you need.
We’ll walk you through 15 sample letters that show you how to appeal an insurance denial for medical necessity.
From gathering evidence to crafting a persuasive argument, these letters cover common scenarios and offer proven strategies for getting your claim approved.
By the end, you’ll have the tools and confidence to advocate for the coverage you deserve. Let’s get started.
Sample Letters of Appeal for Medical Necessity
Letter 1: Appeal for Spinal Fusion Surgery
Subject: Appeal for Denial of Coverage – Spinal Fusion Surgery (Claim #123456)
Dear Appeals Committee,
I am writing to appeal the denial of coverage for the L4-L5 lumbar spinal fusion surgery prescribed by my orthopedic surgeon, Dr. John Smith. On March 15, 2023, I received a letter stating that my request for pre-authorization was denied because the procedure was deemed not medically necessary.
However, as detailed in the attached medical records, I have been suffering from severe, debilitating lower back pain for over a year due to spinal stenosis and degenerative disc disease. Conservative treatments such as physical therapy, medication, and epidural injections have failed to provide relief. My MRI shows significant narrowing of the spinal canal and nerve root compression at L4-L5. Dr. Smith, a highly respected spine specialist, has determined that spinal fusion surgery is the only remaining option to alleviate my pain, restore function, and prevent further damage.
Without this surgery, I am unable to work, care for my family, or perform basic daily activities. My quality of life has deteriorated substantially. I urge you to reconsider your decision based on the clear medical necessity of this procedure in my case. Please review the enclosed documentation, which includes:
- Detailed medical history and records of failed conservative treatments
- MRI and X-ray imaging showing spinal pathology
- Letter from Dr. Smith explaining the medical rationale for surgery
- Peer-reviewed studies supporting the efficacy of spinal fusion for my condition
Thank you for your prompt attention to this urgent matter. I look forward to a favorable resolution so I can proceed with this life-changing surgery. Please contact me if you require any additional information.
Sincerely,
[Your Name]
Letter 2: Appeal for Proton Beam Radiation Therapy
Subject: Appeal for Denial of Coverage – Proton Beam Radiation Therapy (Claim #789012)
Dear Appeals Department,
I am writing to appeal your decision to deny coverage for proton beam radiation therapy to treat my prostate cancer, as recommended by my radiation oncologist, Dr. Sarah Johnson. In your denial letter dated April 1, 2023, you stated that proton therapy was considered investigational and not medically necessary compared to conventional radiation.
I strongly disagree with this assessment. As a 55-year-old with early-stage prostate cancer, I am an ideal candidate for proton therapy. This advanced treatment allows for precise targeting of the tumor while minimizing radiation exposure to healthy tissues, such as the bladder and rectum. This is especially important given my young age and desire to avoid long-term side effects that could greatly impact my quality of life.
Dr. Johnson has extensive experience with proton therapy and believes it offers me the best chance for a cure with the fewest risks. She has provided a detailed letter outlining the medical necessity of this treatment in my specific case, including:
- My age, overall health, and stage of prostate cancer
- The proximity of the prostate to critical structures
- Dosimetry studies showing superior radiation coverage with proton therapy
- Clinical trial data demonstrating excellent outcomes and low toxicity
Additionally, the National Comprehensive Cancer Network (NCCN) guidelines now include proton therapy as a standard treatment option for prostate cancer in appropriately selected patients. This underscores the mainstream acceptance and proven efficacy of this modality.
I am fully prepared to engage in a peer-to-peer review or provide any additional documentation needed to overturn this denial. Proton therapy is medically necessary for me, and I am confident that a thorough review of the evidence will support this position.
Thank you for reconsidering my case. I appreciate your timely response so I can begin treatment without delay.
Sincerely,
[Your Name]
Letter 3: Appeal for Intravenous Immunoglobulin (IVIG) Therapy
Subject: Appeal for Denial of Coverage – Intravenous Immunoglobulin (IVIG) Therapy (Claim #345678)
Dear Appeals Review Board,
I am writing to appeal the denial of coverage for intravenous immunoglobulin (IVIG) therapy prescribed by my neurologist, Dr. Robert Patel, for the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP). Your denial letter dated May 1, 2023, stated that IVIG was not medically necessary because my symptoms were not severe enough to warrant this treatment.
However, as clearly documented in my medical records, I have been struggling with progressive muscle weakness, numbness, and balance issues for several months. These symptoms have significantly impaired my ability to work, drive, and perform everyday tasks. Dr. Patel has diagnosed me with CIDP based on clinical presentation, neurological exam findings, and electrodiagnostic studies showing demyelination of my peripheral nerves.
IVIG is a well-established, first-line treatment for CIDP, as supported by numerous clinical trials and expert consensus guidelines. It works by modulating the immune system to prevent further damage to the nerves. Dr. Patel strongly believes that IVIG is medically necessary to halt the progression of my disease, improve my neurological function, and prevent long-term disability.
Enclosed, please find the following supporting documentation:
- Detailed medical history and neurological exam findings
- Electrodiagnostic study results confirming CIDP diagnosis
- Letter from Dr. Patel explaining the medical necessity of IVIG for my case
- Relevant medical literature on the efficacy of IVIG for CIDP
I kindly request that you reconsider your decision based on this compelling evidence. IVIG is not an investigational treatment, but rather a proven therapy that is essential for managing my condition. I am willing to provide any additional information you may require or participate in a peer-to-peer review to discuss my case further.
Thank you for your careful consideration of my appeal. I look forward to your timely response so I can start this medically necessary treatment without further delay.
Sincerely,
[Your Name]
Letter 4: Appeal for Bilateral Cochlear Implants
Subject: Appeal for Denial of Coverage – Bilateral Cochlear Implants (Claim #901234)
Dear Appeals Committee,
I am writing to appeal your decision to deny coverage for bilateral cochlear implants for my 2-year-old son, Max, who has profound sensorineural hearing loss in both ears. In your denial letter dated June 1, 2023, you stated that bilateral implantation was not medically necessary and that a single implant would suffice.
I strongly disagree with this assessment, as does Max’s entire medical team, including his pediatric otolaryngologist, audiologist, and speech-language pathologist. Max was born with severe to profound hearing loss and has failed to benefit from traditional hearing aids. Without access to sound in both ears during this critical period of brain development, Max is at risk for significant delays in speech, language, and cognitive skills.
Bilateral cochlear implants are the standard of care for children like Max, as they provide binaural hearing, improved sound localization, and better speech understanding in noisy environments. This is crucial for Max’s safety, social-emotional development, and overall quality of life. Denying him access to this medically necessary treatment could have profound, lifelong consequences.
Enclosed, please find comprehensive documentation supporting the medical necessity of bilateral cochlear implants in Max’s case, including:
- Detailed medical history and audiological evaluations showing profound deafness
- Letters from Max’s medical team explaining the importance of bilateral implantation
- Journal articles demonstrating superior outcomes with bilateral vs. unilateral implants
- FDA approval and clinical practice guidelines supporting bilateral implantation in children
On behalf of Max, I urge you to reconsider your decision and approve coverage for bilateral cochlear implants. This is not a cosmetic or elective procedure, but a vital medical intervention that will give Max the best chance to develop normal hearing and reach his full potential.
Thank you for your prompt attention to this life-altering matter. Please feel free to contact me or Max’s medical team if you require any clarification or additional information.
Sincerely,
[Your Name]
Letter 5: Appeal for Bariatric Surgery
Subject: Appeal for Denial of Coverage – Roux-en-Y Gastric Bypass Surgery (Claim #567890)
Dear Appeals Department,
I am writing to appeal the denial of coverage for Roux-en-Y gastric bypass surgery, as recommended by my bariatric surgeon, Dr. Emily Chen. In your denial letter dated July 1, 2023, you stated that this procedure was not medically necessary and that I should continue with conservative weight loss measures.
However, as detailed in my medical records, I have been struggling with severe obesity for over a decade, with a current BMI of 45. This has led to multiple obesity-related comorbidities, including type 2 diabetes, hypertension, sleep apnea, and debilitating joint pain. Despite numerous attempts at diet, exercise, and medication, I have been unable to achieve significant, sustained weight loss.
Dr. Chen, who is a renowned expert in bariatric surgery, has determined that gastric bypass is medically necessary in my case to address my obesity and related health issues. This procedure has been extensively studied and proven to be a safe, effective treatment for severe obesity when other methods have failed. It offers the best chance for long-term weight loss, resolution of comorbidities, and improved quality of life.
Enclosed, please find the following documentation supporting the medical necessity of gastric bypass surgery in my case:
- Detailed medical history, including failed conservative weight loss attempts
- Records of obesity-related comorbidities and their impact on my health
- Letter from Dr. Chen outlining the indications and expected benefits of surgery
- Peer-reviewed studies demonstrating the efficacy and safety of gastric bypass
I kindly request that you reconsider your decision based on this strong evidence. Bariatric surgery is not a cosmetic procedure, but a vital medical intervention that can greatly improve my health and potentially save my life. I am fully committed to the necessary lifestyle changes and follow-up care to ensure the best possible outcome.
Thank you for your thorough review of my appeal. I am happy to provide any additional information needed or participate in a peer-to-peer discussion with your medical director. Please respond promptly so I can move forward with this life-changing treatment.
Sincerely,
[Your Name]
Letter 6: Appeal for Blepharoplasty
Subject: Appeal for Denial of Coverage – Functional Blepharoplasty (Claim #234567)
Dear Appeals Review Board,
I am writing to appeal your decision to deny coverage for functional blepharoplasty, as prescribed by my oculoplastic surgeon, Dr. David Lee. In your denial letter dated August 1, 2023, you stated that this procedure was considered cosmetic and not medically necessary.
I strongly disagree with this assessment. As clearly documented in my medical records, I have severe dermatochalasis (excess eyelid skin) that is causing significant functional impairment. The redundant skin is hanging over my eyelashes, blocking my superior and peripheral vision. This has led to difficulty reading, driving, and performing daily activities. I have also experienced chronic eye irritation and headaches as a result of straining to see.
Dr. Lee has determined that blepharoplasty is medically necessary to remove the excess skin and restore my visual function. This is not a cosmetic procedure, but a functional surgery to address a documented medical condition that is impacting my quality of life. Blepharoplasty is a well-established treatment for dermatochalasis, as supported by medical literature and standard clinical practice guidelines.
Enclosed, please find compelling evidence supporting the medical necessity of blepharoplasty in my case, including:
- Detailed medical history and exam findings documenting functional impairment
- Visual field testing showing superior and peripheral vision loss
- Photographs demonstrating the extent of dermatochalasis
- Letter from Dr. Lee explaining the medical rationale for blepharoplasty
- Relevant journal articles on the functional indications for blepharoplasty
I urge you to reconsider your decision based on this clear and convincing documentation. Denying coverage for this medically necessary procedure would be detrimental to my vision, safety, and overall wellbeing. I am prepared to provide any additional information you may require or participate in a peer-to-peer review to discuss my case in more detail.
Thank you for your prompt attention to this important matter. I look forward to a favorable resolution so I can proceed with this sight-restoring surgery without further delay.
Sincerely,
[Your Name]
Letter 7: Appeal for Power Wheelchair
Subject: Appeal for Denial of Coverage – Power Wheelchair (Claim #890123)
Dear Appeals Committee,
I am writing to appeal your decision to deny coverage for a power wheelchair, as prescribed by my neurologist, Dr. Lisa Patel. In your denial letter dated September 1, 2023, you stated that a manual wheelchair would be sufficient to meet my mobility needs.
However, as clearly outlined in my medical records, I have been diagnosed with advanced multiple sclerosis and am no longer able to safely propel a manual wheelchair due to significant upper extremity weakness and fatigue. I require a power wheelchair for independent mobility within my home and community. Without it, I am essentially homebound and unable to perform basic activities of daily living or participate in essential medical appointments.
Dr. Patel has determined that a power wheelchair is medically necessary to accommodate my progressive disability and prevent further deconditioning. She has provided a detailed letter of medical necessity, along with the following supporting documentation:
- Comprehensive medical history and neurological exam findings
- Occupational therapy evaluation demonstrating upper extremity weakness
- Specialty evaluation confirming need for power mobility
- Relevant medical literature on the benefits of power wheelchairs for advanced MS
Denying coverage for this essential piece of medical equipment would greatly compromise my safety, independence, and quality of life. It is not a convenience item, but a vital tool for managing my condition and maintaining my health and well-being.
I kindly request that you reconsider your decision based on the strong medical evidence provided. I am fully prepared to engage in a peer-to-peer review or provide any additional documentation needed to support my case.
Thank you for your careful consideration of my appeal. Please respond promptly so I can obtain this medically necessary equipment without further delay.
Sincerely,
[Your Name]
Letter 8: Appeal for Breast Reduction Surgery
Subject: Appeal for Denial of Coverage – Breast Reduction Surgery (Claim #456789)
Dear Appeals Department,
I am writing to appeal your decision to deny coverage for breast reduction surgery, as recommended by my plastic surgeon, Dr. Sarah Johnson. In your denial letter dated October 1, 2023, you stated that this procedure was considered cosmetic and not medically necessary.
I strongly disagree with this assessment, as I have been suffering from severe physical and emotional symptoms related to my macromastia (overly large breasts) for many years. As detailed in my medical records, my size 38H breasts have caused chronic neck, back, and shoulder pain, as well as deep shoulder grooves from my bra straps. I also experience frequent skin rashes and infections under my breasts. These symptoms have significantly impacted my ability to exercise, sleep comfortably, and perform daily activities.
Additionally, the emotional toll of my condition cannot be overstated. I have struggled with self-consciousness, low self-esteem, and difficulty finding properly fitting clothing. This has led to social isolation and depression.
Dr. Johnson has determined that breast reduction surgery is medically necessary to alleviate my symptoms and improve my overall health and well-being. She has provided a detailed letter of medical necessity, along with the following supporting documentation:
- Comprehensive medical history and physical exam findings
- Photographs demonstrating the size and ptosis of my breasts
- Records of failed conservative treatments, such as physical therapy and pain medication
- Relevant medical literature on the physical and psychological indications for reduction
Breast reduction surgery is not a cosmetic procedure in my case, but a medically necessary intervention to address a documented condition that is greatly impacting my quality of life. Denying coverage for this surgery would be detrimental to my physical and mental health.
I urge you to reconsider your decision based on the compelling evidence provided. I am happy to participate in a peer-to-peer review or provide any additional information needed to support my case.
Thank you for your prompt attention to this important matter. I look forward to a favorable resolution so I can proceed with this life-changing surgery.
Sincerely,
[Your Name]
Letter 9: Appeal for Hearing Aids
Subject: Appeal for Denial of Coverage – Hearing Aids (Claim #678901)
Dear Appeals Review Board,
I am writing to appeal your decision to deny coverage for bilateral hearing aids, as prescribed by my audiologist, Dr. Michael Chen. In your denial letter dated November 1, 2023, you stated that hearing aids are not covered under my plan and are considered elective.
However, as clearly documented in my medical records, I have bilateral moderate-to-severe sensorineural hearing loss that significantly impacts my daily functioning and quality of life. Without hearing aids, I struggle to communicate with others, participate in social activities, and perform my job duties effectively. This has led to feelings of isolation, frustration, and depression.
Dr. Chen has determined that hearing aids are medically necessary to address my hearing loss and improve my overall well-being. He has provided a detailed letter of medical necessity, along with the following supporting documentation:
- Comprehensive audiological evaluation showing the extent and type of hearing loss
- Speech recognition testing demonstrating difficulty understanding speech
- Records of failed conservative treatments, such as assistive listening devices
- Relevant medical literature on the benefits of hearing aids for sensorineural loss
Denying coverage for these essential medical devices would greatly compromise my ability to engage in basic activities and maintain my independence. Hearing aids are not a luxury or cosmetic item, but a vital treatment for a documented medical condition.
I kindly request that you reconsider your decision based on the strong medical evidence provided. I am fully prepared to engage in a peer-to-peer review or provide any additional documentation needed to support my case.
Thank you for your careful consideration of my appeal. Please respond promptly so I can obtain these medically necessary devices without further delay.
Sincerely,
[Your Name]
Letter 10: Appeal for Physical Therapy
Subject: Appeal for Denial of Coverage – Physical Therapy (Claim #012345)
Dear Appeals Committee,
I am writing to appeal your decision to deny coverage for ongoing physical therapy, as prescribed by my orthopedic surgeon, Dr. Jessica Lee, following my total knee replacement surgery. In your denial letter dated December 1, 2023, you stated that further therapy was not medically necessary and that I should be able to continue my exercises independently at this stage of recovery.
However, as clearly outlined in my medical records and progress notes, I am still experiencing significant stiffness, weakness, and limited range of motion in my operated knee, which are impeding my ability to perform essential daily activities and return to work. I have diligently attended all of my prescribed therapy sessions and have been performing my home exercise program, but I require ongoing skilled therapy to achieve optimal recovery and prevent complications.
Dr. Lee has provided a detailed letter of medical necessity, along with the following supporting documentation:
- Operative report and post-surgical rehabilitation protocol
- Physical therapy evaluation and progress notes showing objective deficits
- Range of motion and strength measurements demonstrating continued limitations
- Relevant medical literature on the importance of supervised therapy after knee replacement
Denying coverage for medically necessary physical therapy at this critical stage of my recovery would greatly compromise my functional outcomes and long-term quality of life. It could also lead to costly complications and potential additional surgeries down the road.
I urge you to reconsider your decision based on the compelling medical evidence provided. I am fully committed to my rehabilitation and am eager to return to my pre-surgical level of function with the help of ongoing professional guidance.
Thank you for your prompt attention to this important matter. I am happy to provide any additional information or participate in a peer-to-peer review to discuss my case further.
Sincerely,
[Your Name]
Wrap-up: The Power of a Strong Letter of Appeal
Receiving a denial letter from your insurance company for a medically necessary treatment can be disheartening, but it’s not the end of the road.
By crafting a strong letter of appeal, you can make a compelling case for why your claim should be approved and get the care you need.
The key to a successful appeal is providing clear, objective evidence that demonstrates the medical necessity of the requested treatment.
This includes detailed medical records, doctor’s notes, test results, and relevant medical literature.
It’s also important to tell your personal story and explain how the denial is impacting your health and quality of life.
Remember, insurance companies are not always right, and you have the right to challenge their decisions.
With persistence, patience, and a well-written appeal, you can overcome coverage denials and access the medically necessary care you deserve.
Don’t give up hope. Use these sample letters as a guide, and work closely with your healthcare team to build the strongest case possible.
Your health is worth fighting for.