Medical necessity appeal letter template pdf

Medical necessity appeals are written when health plans deny coverage for medical services, treatments, or drugs. This type of letter is often required when a medical service or product is determined to be “not medically necessary” by an insurance company.

When writing a medical necessity appeal letter, it is important to include all necessary information to ensure your appeal is successful. Below you will find a template that includes all of the important points that you will need to cover:

[Your Name]
[Your address]
[City, State, ZIP Code]
[Your phone number]
[Your email address]
[Insurance Company Name]
[City, State, Zip Code]

Medical necessity appeal letter template pdf Download

Dear Sir or Madam,

I write this letter to appeal the denial of coverage for [name of medical service, treatment or drug] submitted under [policy no.] dated [date submitted]. The reason given for the denial of coverage was that [state the reason given by the insurance company for denying coverage].

I have consulted with my physician who has confirmed that this medical procedure/treatment/medication is necessary to treat my condition.

I have attached all necessary medical documentation, including test results and physician notes, to support my request. My request is for reconsideration of the denial of coverage for the medical procedure/treatment/medication. As soon as possible, I would appreciate your review and decision.

Thanks in advance for your attention to this matter.


[Your Name]

Medical record support for medical necessity
Notes from physician
Any other information that is relevant

In addition to the items listed above, it is also important to be concise and clear in your letter of appeal. Use plain language and avoid medical jargon or technical terms that may confuse the reader.

It is also important to be aware of your insurance company’s specific requirements with regard to the appeals process. Be sure to follow their specific guidelines and include any necessary documentation or forms they may require.

To summarize, writing a medical necessity appeal letter can be an effective way to challenge an insurance company’s decision to deny coverage for a medical procedure, treatment, or medication. You can ensure that your letter contains all the necessary information and increase the chances of a successful appeal by using a template such as the one provided above.

Medical necessity appeal letter template pdf word sample example