No one looks forward to getting that dreaded letter from their insurance company denying coverage for a medical procedure, medication, or treatment.
It’s frustrating, stressful, and can leave you feeling helpless. But don’t give up hope just yet.
You have the right to appeal an insurance denial, and a well-crafted appeal letter can make all the difference.
By clearly explaining your situation, providing supporting evidence, and knowing your rights, you can increase your chances of getting the coverage you need and deserve.
Sample Letters of Appealing Insurance Denial
Below are 15 sample letters to help guide you in writing your appeal.
Customize them based on your specific situation and insurance plan.
Appeal for Denied Medication Coverage
Subject: Appeal for Denial of Prescription Drug Coverage – Policy #1234567
Dear [Insurance Company],
I am writing to appeal the denial of coverage for my prescribed medication, [Drug Name]. My doctor, [Doctor’s Name], believes this medication is medically necessary to treat my [Condition].
I have tried alternative medications in the past, but they have been ineffective in managing my symptoms. [Doctor’s Name] strongly believes that [Drug Name] is the best course of treatment for my specific case.
Enclosed, please find a letter from [Doctor’s Name] further explaining the medical necessity of this medication. I also included the original prescription and relevant medical records.
I kindly ask that you reconsider your decision and approve coverage for [Drug Name]. If you require any additional information, please contact me or [Doctor’s Name].
Thank you for your time and consideration.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Denied Medical Procedure
Subject: Appeal for Denial of [Procedure Name] – Claim #987654
Dear [Insurance Company],
I am writing to appeal the denial of coverage for [Procedure Name], which my doctor, [Doctor’s Name], deems medically necessary.
[Doctor’s Name] believes that this procedure is crucial for diagnosing/treating my [Condition]. Without it, my health may significantly deteriorate, potentially leading to more serious complications and higher medical costs in the future.
I have enclosed a letter from [Doctor’s Name] detailing the medical reasons for the [Procedure Name], along with my relevant medical records and the original claim.
Please reconsider your decision and approve coverage for this essential procedure. If you need any further information or clarification, please don’t hesitate to contact me or [Doctor’s Name].
Thank you for your attention to this matter.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Denied Pre-Authorization
Subject: Appeal for Pre-Authorization Denial – Request #246813
Dear [Insurance Company],
I am appealing the denial of pre-authorization for [Treatment/Procedure/Medication], as requested by my healthcare provider, [Doctor’s Name], on [Date].
[Doctor’s Name] considers this treatment medically necessary for managing my [Condition]. They have provided a detailed explanation of the treatment plan and its expected benefits in the enclosed letter.
As a policyholder, I am entitled to the benefits outlined in my plan, which I believe should cover this treatment. Denying this pre-authorization could jeopardize my health and well-being.
Please review the attached documents, including the pre-authorization request, [Doctor’s Name]’s letter, and relevant medical records. I urge you to reconsider your decision and grant the pre-authorization for [Treatment/Procedure/Medication].
If you require further information, please contact me or [Doctor’s Name]. Thank you for your prompt attention to this matter.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Out-of-Network Coverage
Subject: Appeal for Out-of-Network Coverage Denial – Claim #135792
Dear [Insurance Company],
I am writing to appeal the denial of coverage for services provided by [Out-of-Network Provider] on [Date of Service].
Due to the specialized nature of my condition, there were no in-network providers with the necessary expertise to effectively treat me. [Out-of-Network Provider] was the closest qualified healthcare professional, and seeking their services was essential for managing my health.
I have enclosed a letter from my primary care physician, [Doctor’s Name], explaining why [Out-of-Network Provider]’s services were medically necessary. I also included the original claim and relevant medical records.
Given these circumstances, I kindly request that you make an exception and cover the services provided by [Out-of-Network Provider] at the in-network rate.
Please review the attached documents and reconsider your decision. If you need any additional information, feel free to contact me.
Thank you for your understanding and consideration.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Emergency Room Visit Coverage
Subject: Appeal for Emergency Room Visit Denial – Claim #864297
Dear [Insurance Company],
I am appealing the denial of coverage for my emergency room visit on [Date] at [Hospital Name].
I sought emergency care due to [Describe Symptoms], which I believed posed a serious threat to my health. At the time, I acted on the prudent layperson standard, meaning a person with average medical knowledge would reasonably believe that not seeking immediate medical attention could result in serious harm.
The enclosed hospital records detail my symptoms, examination, and treatment plan. I also included a letter from the attending physician explaining the medical necessity of the emergency room visit.
Based on my policy’s emergency care coverage and the circumstances surrounding my visit, I request that you reconsider the denial and cover the associated costs.
Please review the attached documents and contact me if you require further information.
Thank you for your timely attention to this matter.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Denied Mental Health Services
Subject: Appeal for Mental Health Services Denial – Claim #571283
Dear [Insurance Company],
I am writing to appeal the denial of coverage for mental health services provided by [Therapist Name] on [Date].
Mental health is just as important as physical health, and my policy states that it covers necessary mental health treatments. [Therapist Name] deemed these services essential for managing my [Mental Health Condition], as explained in their enclosed letter.
I have been struggling with [Symptoms], which significantly impact my daily life and overall well-being. Denying coverage for these crucial services could lead to a worsening of my condition and potential long-term consequences.
Please reconsider your decision and approve coverage for my mental health treatment. I have attached the original claim, [Therapist Name]’s letter, and relevant medical records for your review.
If you need any additional information, please contact me or [Therapist Name].
Thank you for your understanding and prompt attention to this appeal.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Physical Therapy Coverage
Subject: Appeal for Physical Therapy Denial – Claim #902345
Dear [Insurance Company],
I am appealing the denial of coverage for physical therapy services provided by [Physical Therapist Name] on [Date].
After [Injury/Surgery], my doctor recommended physical therapy as a necessary step in my recovery process. [Physical Therapist Name] developed a tailored treatment plan to help me regain strength, mobility, and function.
Denying coverage for these services could hinder my recovery and potentially lead to long-term complications. This, in turn, could result in additional medical expenses down the line.
I have enclosed a letter from my doctor explaining the medical necessity of physical therapy, along with the original claim and relevant medical records.
Please review the attached documents and reconsider your decision to deny coverage. If you require any further information, feel free to contact me or [Physical Therapist Name].
Thank you for your consideration and timely response to this appeal.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Durable Medical Equipment
Subject: Appeal for Durable Medical Equipment Denial – Claim #468027
Dear [Insurance Company],
I am writing to appeal the denial of coverage for [Durable Medical Equipment] prescribed by my doctor, [Doctor’s Name], on [Date].
[Doctor’s Name] believes this equipment is medically necessary for managing my [Condition]. They have provided a detailed explanation of how it will improve my quality of life and prevent potential complications in the enclosed letter.
My policy’s durable medical equipment coverage should apply to this essential item. Denying coverage would place an undue financial burden on me and limit my ability to manage my condition effectively.
Please reconsider your decision and approve coverage for [Durable Medical Equipment]. I have attached the original prescription, [Doctor’s Name]’s letter, and relevant medical records for your review.
If you need any additional information, please don’t hesitate to contact me or [Doctor’s Name].
Thank you for your attention to this matter and your timely response.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Denied Specialist Referral
Subject: Appeal for Specialist Referral Denial – Authorization #753951
Dear [Insurance Company],
I am appealing the denial of a specialist referral to [Specialist Name] for [Condition/Reason], as requested by my primary care physician, [Doctor’s Name], on [Date].
[Doctor’s Name] believes that seeing [Specialist Name] is crucial for diagnosing and treating my [Condition]. They have exhausted all available options within their scope of practice, and my condition requires the expertise of a specialist.
Enclosed, please find a letter from [Doctor’s Name] detailing the medical necessity for this referral and my relevant medical records.
I kindly ask that you reconsider your decision and authorize the referral to [Specialist Name]. Denying this referral could delay proper diagnosis and treatment, potentially worsening my condition and leading to higher medical costs in the future.
If you require further information, please contact me or [Doctor’s Name]. Thank you for your prompt attention to this appeal.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Home Health Care Coverage
Subject: Appeal for Home Health Care Denial – Claim #159432
Dear [Insurance Company],
I am writing to appeal the denial of coverage for home health care services prescribed by my doctor, [Doctor’s Name], on [Date].
Following my [Illness/Injury/Surgery], [Doctor’s Name] determined that home health care is medically necessary for my recovery and to prevent complications. The services include [List Services], which are essential for my healing process and overall well-being.
My policy includes coverage for medically necessary home health care. Denying these services would impede my recovery and could lead to rehospitalization or prolonged health issues.
Please review the attached letter from [Doctor’s Name], the original claim, and my relevant medical records. I request that you reconsider your decision and approve coverage for my prescribed home health care services.
If you need additional information, please contact me or [Doctor’s Name]. Thank you for your consideration and timely response to this appeal.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Denied Imaging Study
Subject: Appeal for Imaging Study Denial – Claim #246810
Dear [Insurance Company],
I am appealing the denial of coverage for [Imaging Study] ordered by my healthcare provider, [Doctor’s Name], on [Date].
[Doctor’s Name] believes this imaging study is medically necessary to diagnose my [Symptoms/Condition] accurately. Without a proper diagnosis, my treatment plan may be delayed or inadequate, potentially leading to worsened health outcomes.
Enclosed, please find a letter from [Doctor’s Name] explaining the medical necessity of the [Imaging Study], along with the original claim and relevant medical records.
I kindly request that you reconsider your decision and approve coverage for this essential diagnostic tool. If you require further information, please don’t hesitate to contact me or [Doctor’s Name].
Thank you for your attention to this appeal and your timely response.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Behavioral Therapy Coverage
Subject: Appeal for Behavioral Therapy Denial – Claim #369147
Dear [Insurance Company],
I am writing to appeal the denial of coverage for behavioral therapy services provided by [Therapist Name] for my child, [Child’s Name], on [Date].
[Child’s Name] has been diagnosed with [Condition], and their pediatrician, [Doctor’s Name], has prescribed behavioral therapy as a necessary treatment. This therapy is crucial for helping [Child’s Name] develop coping skills, improve communication, and enhance their overall quality of life.
My policy includes coverage for medically necessary behavioral therapy services. Denying these services could hinder my child’s development and lead to long-term challenges.
I have attached a letter from [Doctor’s Name] detailing the medical necessity of behavioral therapy for [Child’s Name], along with the original claim and relevant medical records.
Please reconsider your decision and approve coverage for my child’s essential behavioral therapy services. If you need additional information, feel free to contact me or [Doctor’s Name].
Thank you for your consideration and prompt attention to this appeal.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Occupational Therapy Coverage
Subject: Appeal for Occupational Therapy Denial – Claim #789123
Dear [Insurance Company],
I am appealing the denial of coverage for occupational therapy services provided by [Occupational Therapist Name] on [Date].
Following my [Injury/Surgery/Condition], my doctor recommended occupational therapy to help me regain the skills necessary for daily living and return to work. [Occupational Therapist Name] has developed a personalized treatment plan to address my specific needs and goals.
Denying coverage for these services would significantly impact my ability to recover and resume my normal activities. This could lead to prolonged disability and potential job loss.
I have enclosed a letter from my doctor explaining the medical necessity of occupational therapy, along with the original claim and relevant medical records.
Please review the attached documents and reconsider your decision to deny coverage. If you require any further information, feel free to contact me or [Occupational Therapist Name].
Thank you for your attention to this matter and your timely response.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Speech Therapy Coverage
Subject: Appeal for Speech Therapy Denial – Claim #147258
Dear [Insurance Company],
I am writing to appeal the denial of coverage for speech therapy services provided by [Speech Therapist Name] for my child, [Child’s Name], on [Date].
[Child’s Name] has been diagnosed with [Condition], which has significantly impacted their speech and language development. Their pediatrician, [Doctor’s Name], has prescribed speech therapy as a necessary treatment to help them communicate effectively and reach age-appropriate milestones.
My policy includes coverage for medically necessary speech therapy services. Denying these services could hinder my child’s development and lead to long-term educational and social challenges.
I have attached a letter from [Doctor’s Name] detailing the medical necessity of speech therapy for [Child’s Name], along with the original claim and relevant medical records.
Please reconsider your decision and approve coverage for my child’s essential speech therapy services. If you need additional information, feel free to contact me or [Doctor’s Name].
Thank you for your consideration and prompt attention to this appeal.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Appeal for Genetic Testing Coverage
Subject: Appeal for Genetic Testing Denial – Claim #963852
Dear [Insurance Company],
I am appealing the denial of coverage for genetic testing ordered by my healthcare provider, [Doctor’s Name], on [Date].
Due to my family history and personal medical background, [Doctor’s Name] believes genetic testing is medically necessary to assess my risk for [Condition/s]. This information is crucial for developing an appropriate preventive care plan and making informed healthcare decisions.
Enclosed, please find a letter from [Doctor’s Name] explaining the medical necessity of genetic testing in my case, along with the original claim and relevant medical records.
I kindly request that you reconsider your decision and approve coverage for this essential risk assessment tool. Denying coverage could prevent me from receiving timely and appropriate medical care.
If you require further information, please don’t hesitate to contact me or [Doctor’s Name]. Thank you for your attention to this appeal and your timely response.
Sincerely,
[Your Name]
[Policy Number]
[Contact Information]
Wrap-up on Appealing Insurance Denials
Receiving an insurance denial can be disheartening, but it’s important to remember that you have the right to appeal.
By crafting a clear, concise, and persuasive appeal letter, you can increase your chances of getting the coverage you need.
Be sure to include all relevant information, such as claim numbers, policy details, and supporting documents from your healthcare providers.
Stay polite and professional throughout the letter, and clearly explain why the denied service or treatment is medically necessary.
If your initial appeal is denied, don’t give up.
You may have the option to request an external review or seek help from your state’s insurance commissioner, persistence and patience are key when navigating the appeals process.
Remember, you are your own best advocate when it comes to your health and well-being.
By understanding your insurance policy and being proactive in your communication with your insurance company, you can ensure that you receive the care and coverage you deserve.