Date

Name
Insurance Company name
Address
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