Facing a medical situation can be hard and stressful, especially when insurance claims are denied or coverage is not enough.
In these difficult moments, a well-written appeal letter can be a powerful tool to get the medical help you need.
An appeal letter is your opportunity to make a strong case, give more information, and convince the decision-maker to rethink their initial choice.
With the right approach, you can improve your chances of getting the medical support you deserve.
Keep reading for 15 sample letters to help guide you in writing your effective appeal.
Sample Letters of Appeal for Medical Assistance
The following 15 sample letters cover various situations where you may need to appeal for medical assistance:
1. Appeal for Denied Insurance Coverage
Subject: Appeal for Denied Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am writing to appeal the denial of coverage for [medical procedure/treatment] under my insurance policy, [policy number]. The denial letter, dated [denial date], stated that the [procedure/treatment] was not medically necessary.
However, my doctor, [doctor’s name], has determined that this [procedure/treatment] is essential for treating my [medical condition]. I have enclosed a letter from [doctor’s name] explaining the medical necessity of this [procedure/treatment], along with relevant medical records and test results.
Please reconsider your decision and approve coverage for this vital [procedure/treatment]. Without it, my health and quality of life will be significantly affected.
Thank you for your time and consideration. I look forward to a positive resolution to this matter.
Sincerely,
[Your Name]
2. Appeal for Additional Physical Therapy Sessions
Subject: Appeal for Additional Physical Therapy – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am writing to request additional physical therapy sessions beyond the initially approved number under my insurance policy, [policy number]. While I appreciate the sessions already granted, my recovery requires ongoing therapy to achieve the best results.
My physical therapist, [therapist’s name], has provided a detailed treatment plan showing the need for continued sessions. I have attached this plan, along with progress notes demonstrating the improvements made so far and the potential for more progress with additional therapy.
Limiting my physical therapy now could cause my recovery to slow down or even reverse. I am fully committed to participating in my treatment to regain maximum function and independence.
Please consider approving additional physical therapy sessions as outlined in the attached treatment plan. Your support in my recovery journey is greatly appreciated.
Thank you for your attention to this matter.
Sincerely,
[Your Name]
3. Appeal for Out-of-Network Provider Coverage
Subject: Appeal for Out-of-Network Provider – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am reaching out to request coverage for treatment by an out-of-network provider, [provider’s name], under my insurance policy, [policy number]. While I understand you prefer in-network providers, I believe an exception is warranted in this case.
[Provider’s name] is a highly regarded specialist in treating [medical condition]. After much research and talks with my primary care doctor, it is clear that [provider’s name] offers expertise and treatment options not easily available from in-network providers.
Denying access to this specialist could greatly impact the quality and effectiveness of my care. I am willing to work with you to find a solution we both agree on, such as a single-case agreement or a one-time exception.
I have included a letter from my primary care doctor supporting this request, along with information about [provider’s name]’s unique qualifications and treatment approach.
Please consider granting coverage for treatment by [provider’s name]. I am confident that this partnership will lead to the best possible outcome for my health.
Thank you for your understanding and cooperation.
Sincerely,
[Your Name]
4. Appeal for Prescription Drug Coverage
Subject: Appeal for Prescription Drug Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am writing to appeal the denial of coverage for the prescription drug [drug name] under my insurance policy, [policy number]. This medication has been prescribed by my doctor, [doctor’s name], to treat my [medical condition].
The denial letter, dated [denial date], cited the reason for denial as the drug not being on your approved drug list. However, my doctor has tried several approved alternatives without success. [Drug name] is the only medication that effectively manages my condition with minimal side effects.
I have enclosed a letter from [doctor’s name] detailing my treatment history, the failure of approved options, and the medical necessity of [drug name]. Also included are relevant medical records and scientific literature supporting the use of [drug name] for my condition.
Please reconsider your decision and approve coverage for [drug name]. Having access to this medication is very important for maintaining my health and preventing potential complications.
Thank you for your prompt attention to this matter. I appreciate your understanding and look forward to a positive outcome.
Sincerely,
[Your Name]
5. Appeal for Inpatient Hospital Stay
Subject: Appeal for Inpatient Hospital Stay – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am appealing the denial of coverage for my recent inpatient hospital stay from [admission date] to [discharge date] under my insurance policy, [policy number]. The denial letter, dated [denial date], indicated that the hospital stay was not medically necessary.
However, my admitting doctor, [doctor’s name], determined that inpatient care was essential for properly managing my [medical condition]. Outpatient treatment or a shorter hospital stay would not have been enough to deal with my serious symptoms and potential complications.
Enclosed is a detailed letter from [doctor’s name] explaining the reasons for inpatient admission, along with my hospital records, test results, and treatment plan. These documents show the medical necessity of my hospital stay.
Please reevaluate your decision and approve coverage for my inpatient hospital stay. Proper inpatient care was critical for my recovery and overall well-being.
Thank you for reconsidering this matter. After reviewing the enclosed information, I trust you will agree that the inpatient stay was indeed medically necessary.
Sincerely,
[Your Name]
6. Appeal for Skilled Nursing Facility Coverage
Subject: Appeal for Skilled Nursing Facility Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am writing to appeal the denial of coverage for my stay at [skilled nursing facility name] from [admission date] to [discharge date] under my insurance policy, [policy number]. The denial letter, dated [denial date], stated that skilled nursing care was not medically necessary.
After my [hospital stay/surgery], my doctor, [doctor’s name], determined that I required continued skilled nursing care and rehabilitation to safely recover and regain essential functions. [Skilled nursing facility name] provided the necessary round-the-clock nursing care, therapy services, and medical supervision to support my recovery.
I have attached a letter from [doctor’s name] detailing my medical condition, the need for skilled nursing care, and my progress during the facility stay. Also included are my facility records, therapy notes, and discharge summary, which further demonstrate the medical necessity of this care.
Please reconsider your decision and approve coverage for my skilled nursing facility stay. Access to this level of care was vital for my safe and effective recovery.
Thank you for your attention to this matter. I am confident that upon reviewing the enclosed documentation, you will understand the necessity of the skilled nursing care I received.
Sincerely,
[Your Name]
7. Appeal for Home Health Care Coverage
Subject: Appeal for Home Health Care Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am appealing the denial of coverage for home health care services under my insurance policy, [policy number]. The denial letter, dated [denial date], indicated that the requested services were not medically necessary.
After my recent [hospitalization/surgery], my doctor, [doctor’s name], ordered home health care to help with my recovery and prevent complications. The services requested, including skilled nursing visits, physical therapy, and help with daily living activities, are essential for my safe recovery and improved functional ability.
Enclosed is a letter from [doctor’s name] describing my medical condition, the need for home health care, and the specific services prescribed. I have also included my hospital discharge summary and initial home health care assessment, which further support the medical necessity of these services.
Please reconsider your decision and approve coverage for the prescribed home health care. Getting these services at home will help my recovery, prevent hospital readmission, and improve my overall well-being.
Thank you for your prompt attention to this appeal. After reviewing the enclosed documents, I trust you will agree that home health care is medically necessary in my case.
Sincerely,
[Your Name]
8. Appeal for Durable Medical Equipment
Subject: Appeal for Durable Medical Equipment – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am writing to appeal the denial of coverage for [specific durable medical equipment] under my insurance policy, [policy number]. The denial letter, dated [denial date], stated that the equipment was not medically necessary.
My doctor, [doctor’s name], has prescribed this equipment to help with my [medical condition] and improve my functional ability. The [specific equipment] is essential for my safety, mobility, and ability to do daily activities.
Enclosed is a letter from [doctor’s name] explaining my medical condition, the need for the prescribed equipment, and how it will benefit my overall health and well-being. I have also included relevant medical records and supporting documents.
Please reconsider your decision and approve coverage for the [specific durable medical equipment]. Having access to this equipment will greatly improve my quality of life and independence.
Thank you for your attention to this matter. I am confident that after reviewing the enclosed information, you will understand the medical necessity of the prescribed equipment.
Sincerely,
[Your Name]
9. Appeal for Mental Health Treatment Coverage
Subject: Appeal for Mental Health Treatment Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am appealing the denial of coverage for [specific mental health treatment] under my insurance policy, [policy number]. The denial letter, dated [denial date], indicated that the treatment was not medically necessary.
My mental health provider, [provider’s name], has determined that this treatment is essential for managing my [mental health condition] and preventing further worsening. Denial of this treatment could lead to serious consequences for my mental well-being and overall functioning.
Enclosed is a letter from [provider’s name] describing my diagnosis, treatment history, and the medical necessity of the requested treatment. I have also included relevant medical records and evidence-based literature supporting the effectiveness of this treatment for my condition.
Please reconsider your decision and approve coverage for the [specific mental health treatment]. Having access to proper mental health care is very important for my recovery and ability to lead a fulfilling life.
Thank you for your prompt attention to this appeal. After reviewing the enclosed information, I trust you will agree that the requested treatment is indeed medically necessary.
Sincerely,
[Your Name]
10. Appeal for Specialty Referral
Subject: Appeal for Specialty Referral – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am writing to appeal the denial of a referral to [specialty] under my insurance policy, [policy number]. The denial letter, dated [denial date], stated that the referral was not medically necessary.
My primary care doctor, [doctor’s name], has determined that a consultation with a [specialty] specialist is crucial for accurately diagnosing and treating my complex medical condition. The expertise of a specialist in this field is essential for making an effective treatment plan and preventing potential complications.
Enclosed is a letter from [doctor’s name] detailing my medical history, current symptoms, and the reasons for the specialty referral. I have also included relevant medical records and test results that show the need for specialized care.
Please reconsider your decision and approve the referral to [specialty]. Having access to this specialized expertise is very important for ensuring the most appropriate and effective care for my condition.
Thank you for your attention to this matter. I am confident that after reviewing the enclosed documentation, you will understand the medical necessity of the requested specialty referral.
Sincerely,
[Your Name]
11. Appeal for Genetic Testing Coverage
Subject: Appeal for Genetic Testing Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am appealing the denial of coverage for [specific genetic testing] under my insurance policy, [policy number]. The denial letter, dated [denial date], indicated that the testing was not medically necessary.
My doctor, [doctor’s name], has recommended this genetic testing to guide treatment decisions and preventive measures for my [medical condition/family history]. The results of this testing will provide critical information for personalized care and improved health outcomes.
Enclosed is a letter from [doctor’s name] explaining my medical history, the importance of the requested genetic testing, and how the results will inform my care. I have also included supporting medical records and scientific literature showing the clinical usefulness of this testing for my specific situation.
Please reconsider your decision and approve coverage for the [specific genetic testing]. Having access to this valuable information is essential for making informed healthcare decisions and optimizing my long-term well-being.
Thank you for your prompt attention to this appeal. After reviewing the enclosed documentation, I trust you will agree that the genetic testing is indeed medically necessary in my case.
Sincerely,
[Your Name]
12. Appeal for Bariatric Surgery Coverage
Subject: Appeal for Bariatric Surgery Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am writing to appeal the denial of coverage for [specific bariatric surgery] under my insurance policy, [policy number]. The denial letter, dated [denial date], stated that the surgery was not medically necessary.
As shown in my medical records, I have been struggling with severe obesity and related health problems despite many attempts at traditional weight loss methods. My doctor, [doctor’s name], has determined that bariatric surgery is a medically necessary treatment to address my obesity and improve my overall health.
Enclosed is a letter from [doctor’s name] detailing my weight history, health conditions, previous weight loss efforts, and the expected benefits of the proposed surgery. I have also included relevant medical records, such as my body mass index (BMI), lab results, and documentation of obesity-related health conditions.
Please reconsider your decision and approve coverage for the [specific bariatric surgery]. This surgery is a critical step in improving my health, reducing the risk of future complications, and enhancing my quality of life.
Thank you for your attention to this matter. I am confident that after reviewing the enclosed documentation, you will understand the medical necessity of the requested bariatric surgery.
Sincerely,
[Your Name]
13. Appeal for Prosthetic Device Coverage
Subject: Appeal for Prosthetic Device Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am appealing the denial of coverage for a [specific prosthetic device] under my insurance policy, [policy number]. The denial letter, dated [denial date], indicated that the device was not medically necessary.
As a result of my [amputation/condition], I require a prosthetic device to restore functional mobility and perform essential daily activities. My prosthetist, [prosthetist’s name], has recommended the [specific prosthetic device] as the most appropriate option for my individual needs and functional goals.
Enclosed is a letter from [prosthetist’s name] describing my medical condition, the necessity of the recommended prosthetic device, and how it will improve my functional capacity and independence. I have also included supporting medical records and documentation from my treating doctor.
Please reconsider your decision and approve coverage for the [specific prosthetic device]. Having access to this device is very important for my mobility, self-care, and overall well-being.
Thank you for your prompt attention to this appeal. After reviewing the enclosed documentation, I trust you will agree that the prosthetic device is indeed medically necessary for my situation.
Sincerely,
[Your Name]
14. Appeal for Hearing Aid Coverage
Subject: Appeal for Hearing Aid Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am writing to appeal the denial of coverage for [specific hearing aids] under my insurance policy, [policy number]. The denial letter, dated [denial date], stated that the hearing aids were not medically necessary.
As shown by my hearing test, I have a significant hearing loss that affects my daily communication, social interactions, and overall quality of life. My audiologist, [audiologist’s name], has recommended the [specific hearing aids] as the most appropriate device to address my hearing needs and improve my functional hearing ability.
Enclosed is a letter from [audiologist’s name] explaining my hearing loss, the necessity of the recommended hearing aids, and how they will benefit my communication and daily functioning. I have also included my hearing test report and relevant medical records.
Please reconsider your decision and approve coverage for the [specific hearing aids]. Having access to these devices is essential for me to effectively communicate, engage in social situations, and maintain my overall well-being.
Thank you for your attention to this matter. I am confident that after reviewing the enclosed documentation, you will understand the medical necessity of the recommended hearing aids.
Sincerely,
[Your Name]
15. Appeal for Substance Abuse Treatment Coverage
Subject: Appeal for Substance Abuse Treatment Coverage – [Your Name] – [Policy Number]
Dear [Insurance Company],
I am appealing the denial of coverage for [specific substance abuse treatment] under my insurance policy, [policy number]. The denial letter, dated [denial date], indicated that the treatment was not medically necessary.
I am appealing the denial of coverage for [specific substance abuse treatment] under my insurance policy, [policy number]. The denial letter, dated [denial date], indicated that the treatment was not medically necessary.
However, my healthcare provider, [provider’s name], has determined that this treatment is crucial for addressing my substance abuse disorder and preventing relapse. Denial of this treatment could jeopardize my recovery and overall well-being.
Enclosed is a letter from [provider’s name] outlining my diagnosis, treatment history, and the medical necessity of the requested treatment. I have also included relevant medical records and evidence-based literature supporting the effectiveness of this treatment for my condition.
Please reconsider your decision and approve coverage for the [specific substance abuse treatment]. Access to comprehensive substance abuse treatment is essential for my sustained recovery and ability to lead a healthy, productive life.
Thank you for your prompt attention to this appeal. I trust that upon reviewing the enclosed documentation, you will agree that the requested treatment is indeed medically necessary for my situation.
Sincerely,
[Your Name]
Wrapping Up: Appeal Letters for Medical Assistance
Navigating the complex world of medical insurance can be challenging, especially when faced with denials or insufficient coverage.
However, by crafting a well-written and persuasive appeal letter, you can advocate for the medical assistance you need and deserve.
These 15 sample letters provide a starting point for various common medical situations that may require an appeal.
Remember, each case is unique, so be sure to customize your letter to your specific circumstances, providing relevant details and supporting documentation.
When writing your appeal letter, be clear, concise, and respectful.
Stick to the facts and avoid emotional language or personal attacks.
Focus on demonstrating the medical necessity of the requested treatment or service and how it will benefit your health and well-being.
If your initial appeal is denied, don’t give up.
You may have the option to file a second-level appeal or seek an external review.
Keep detailed records of all correspondence and documentation related to your appeal.
Remember, you have the right to challenge insurance denials and fight for the medical care you need.
By advocating for yourself and utilizing the power of a well-crafted appeal letter, you can work towards securing the medical assistance necessary for your health and quality of life.