Sample Insurance Denial Appeal Letters

Sample Appeal Letter A
Sample Appeal Letter B

Sample Appeal Letter A

[Date]

[Name]
[Insurance Company Name]
[Address]
[City, State ZIP]

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]


Sample Appeal Letter B

[Date]

[Name]
[Insurance Company Name]
[Address]
[City, State ZIP]

Re: [Patient's Name]
[Type of Coverage]
[Group number/Policy number]

Dear [Name of contact person at insurance company],

Please accept this letter as my 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]

I have been a member of your [state name of PPO, HMO, etc.] since [date]. During that time I have participated within the network of physicians listed by the plan. However, my primary care physician, Dr. [name] believes that the best care for me at this time would be [state procedure name]. At this time there is not a physician within the network who has extensive knowledge of this procedure. Dr. [name of primary care physician], a plan provider, has recommended that I have the procedure done outside the network by Dr. [name of specialist] at [name of treating facility].

I have enclosed a letter from Dr. [name of primary care physician] explaining why he recommends [name of procedure]. I have also enclosed a letter from Dr. [name of specialist] explaining the procedure in detail, his qualifications and experience, and several articles that discuss the procedure.

Based on this information, I am asking that you reconsider your previous decision and allow me to go out of network to Dr. [name] for [name of specific procedure]. The procedure is scheduled to begin on [date]. Should you require additional information, please do not hesitate to contact me at [phone number]. I look forward to hearing from you in the near future.

Sincerely,
[Your name]