Denial of Coverage: Appeal Letter – Example

Last revised: 10/02/2023

Using this Letter

Here’s a template for a letter to appeal a denial of health insurance coverage that incorporates HIPAA compliance considerations.

Be sure to keep copies of all correspondence related to your appeal and send the letter via certified mail with return receipt requested or through a secure method of delivery to ensure that you have documentation of your appeal. Additionally, follow any specific appeals processes outlined by your health insurance company and state regulations and please personalize it with your own information and specific details:

[Your Name] [Your Address] [City, State, ZIP Code] [Your Email Address] [Your Phone Number] [Date]

[Health Insurance Company’s Name] [Claims Department or Customer Service Department] [Address] [City, State, ZIP Code]

Subject: Appeal of Denied Health Insurance Coverage

Policy/Member Number: [Your Policy or Member Number] Claim Number: [Your Claim Number] Date of Denial: [Date of Denial]

To Whom It May Concern,

I am writing to formally appeal the denial of coverage for [describe the denied medical service, treatment, or procedure, including CPT or procedure code, if applicable] under my health insurance policy, referenced above. I received the denial letter dated [Date of Denial], and I am appealing this decision in accordance with the terms and conditions of my policy and my rights under the Health Insurance Portability and Accountability Act (HIPAA).

I believe that the denial of coverage for [specify the medical service] was incorrect for the following reasons:

  1. [Explain the reason for your appeal, including any relevant details about the medical necessity, doctor’s recommendations, or any extenuating circumstances.]
  2. [Provide any supporting documentation, such as medical records, doctor’s notes, or letters of medical necessity, to substantiate your appeal.]
  3. [If applicable, mention any state or federal laws or regulations that support your appeal.]
  4. [Include any additional information or arguments that may be relevant to your case.]

I kindly request that you review my appeal and reconsider the denial of coverage for [specify the medical service]. FAILURE TO PROVIDE IMMEDIATE TREATMENT FOR MY CONDITION INVOLVES AN IMMINENT AND SERIOUS THREAT TO MY HEALTH. I AM, THEREFORE, REQUESTING AN EXPEDITED REVIEW OF MY APPEAL. PLEASE NOTIFY ME OF YOUR DECISION AS SOON AS POSSIBLE, AND NO LATER THAN THREE DAYS, (or the time specified in your health insurance plan), FROM THE DATE OF MY REQUEST. I understand that timely access to appropriate healthcare services is essential for my well-being, and I believe that the requested service is medically necessary.

Please provide me with a written response to this appeal within the timeframe specified by your internal processes and applicable laws and regulations. If additional information or documentation is required to process this appeal, please let me know as soon as possible.

{If you are in a state that has “mandated benefit laws,” or laws that require plans to provide certain coverage, it can be helpful to refer to provisions that mandate coverage for the treatment or service you are seeking. The following language may be appropriate if there are “mandated benefits laws” that apply to your situation. The [medical group or health plan’s failure to provide (name of service, procedure or treatment sought) also violates (name of State) or other law which requires (insert applicable legal requirement) which can be found at (insert applicable safety code # or law.

I appreciate your attention to this matter and your commitment to providing fair and transparent healthcare coverage. I trust that you will give my appeal the careful consideration it deserves.

If you have any questions or require further information, please do not hesitate to contact me at the phone number or email address provided above.

Thank you for your prompt attention to this appeal, and I look forward to a favorable resolution.

Sincerely,

[Your Signature]

[Your Full Name]

cc: {Possible individuals and/or groups to whom you can consider sending copies of your letter:}

[Health Plan Medical Director]
[Medical Group Medical Director]
[Your primary care physician]
[Your specialist]
[Your employer or insurance broker]
[Your state regulatory agency]

Attachments: (Material and documentation you can consider attaching:)

  • Copies of portions of plan member handbook or EOC stating coverage terms, (i.e. specific coverage provisions, and/or definition of medical necessity and list of exclusions and limitations).
  • Copy of referral.
  • Copy of letter from doctor (supporting treatment and supporting need for expedited review, if applicable).
  • Medical records.
  • Medical journal articles supporting medical necessity of care sought.

© Revised from 1999 Center for Health Care Rights