Use this letter as a guideline when appealing a health insurance claim denial. In order for the letter to be effective, you should personalize it by putting it into your own words.
Rewrite the letter,
inserting your personal
information in the
areas indicated in red. You
can print out this
Web page and make
your changes by hand
or copy the body of
the letter and paste
it into a document
where you can make
your changes on your
If you prefer to
see a PDF version of the letter, click here.
Form letter for denial of specific medical procedure
Insurance Company name
City, State and ZIP Code
Re: Patient's Name Type of Coverage Group number/Policy number
Dear Name of contact person at insurance company,
Please accept this letter as patient's name appeal to insurance company name decision to deny coverage for state the name of the specific procedure denied. It is my understanding based on your letter of denial dated insert date that this procedure has been denied because: Quote the specific reason for the denial stated in denial letter.
As you know, patient's name was diagnosed with disease on date. Currently Dr. name believes that patient's name will significantly benefit from state procedure name. Please see the enclosed letter from Dr. name that discusses patient's name medical history in more detail.
Patient's name believes that you did not have all the necessary information at the time of your initial review. Patient's name has also included with this letter, a letter from Dr. name from name of treating facility. Dr. name is a specialist in name of specialty. His/Her letter discusses the procedure in more detail. Also included are medical records and several journal articles explaining the procedure and the results.
Based on this information, patient's name is asking that you reconsider your previous decision and allow coverage for the procedure Dr. name outlines in his letter. The treatment is scheduled to begin on date. Should you require additional information, please do not hesitate to contact patient's name at phone number. Patient's name will look forward to hearing from you in the near future.
Sincerely, Your name
Reproduced with permission from the Patient Advocate Foundation.