Health Insurance Claims: Appeals: Sample Letter: Experimental Treatment
Instructions About The Sample Letter
The sample letter is meant to be be used as a starting point if you are denied a service, procedure or treatment because the insurer says it is "not medically necessary." Feel free to modify it for your particular situation.
There is reference in the sample to two situations: an appeal with urgency due to the need for speed or a regular appeal. If there is any question whether the need is urgent, err on the side of requesting an urgent response.
- For a sample letter about being turned down because the treatment or drug is "medically necessary", click here.
- For a sample letter regarding denial of the right to get a second opinion, click here.
Sample Letter: Appeal For Denial As "Experimental"
[Person's name and title if you have it OR Customer Service Department]
[Name of Your Medical Group OR Health Plan]
RE: Appeal for [your name] OR URGENT APPEAL for [your name]
Subscriber No. [your number]
Dear (person's name if you have it OR Sir/Madam]:
I am writing to appeal [name of medical group OR health plan]'s decision to deny authorizing me to obtain a (treatment/test/drug/category of medical device) which is needed for my medical care.
My doctor, [insert name of doctor], has diagnosed me with ______________ and suggests that I [undergo (describe procedure or treatment); I take (insert name of drug), use (insert name of device)]. This course of treatment is prudent and necessary in order to improve, and ultimately maintain, my health. In the absence of the medically necessary care prescribed by my doctor, my condition will worsen and irrevocably compromise my health. It is medicaly necessary that I take this action as soon as possible.
[Describe treatments which have been tried and when (starting date, and length of treatment). Each of the treatments have ultimately failed.]
As you will see from the enclosed, (the medical literature)(common practice) supports the use of the subject treatment in my situation. (Include summaries and copies of the text of supporting medical literature. If there is no literature. include letters from other doctors indicating that they use the treatment is situations like yours and the reasons. Preferably also include positive results.)
(If the insurer included specifics about why the treatment is not covered, rebut each argument point by point).
[If your life is threatened if you do not get the treatment,
- Check the health insurance law in your state. If you are in a state that provides an exception for coverage of experimental treatments when life is at risk, refer to the provision.You can learn about the law of your state by going to The Actors' Fund Of America's Health Insurance Resource Center (www.ahirc.org ), click on your state, then click on "Insurance Guides" and/or Complaints/Appeals.If you have difficulty, contact your State's Department of Insurance for guidance. For contact information for your state insurance department, see: www.naic.org . Click on "NAIC States and Jurisdictions."
- If there is such a law in your state, the following language may be appropriate: The [medical group OR health plan]'s failure to provide [name of service, procedure OR treatment sought] also violates [name of state in which you reside] law which requires [describe the state's legal requirement]. See [insert the name of your state state, name of law, and section number].
Please reconsider your position and allow my doctor to treat me in accordance with my medical needs and not based on economics. The treatment and/or services prescribed are covered under my plan. No alternative is acceptable to manage my care.
FAILURE TO PROVIDE ME (THIS TEST, THIS TREATMENT, THIS DEVICE) WILL ENTAIL AN IMMINENT AND SERIOUS THREAT TO MY HEALTH. I am therefore requesting an expedited medical review of my appeal for approval of my request for a second opinion.
Please let me know if you need adidtional information.
Please also provide me with a decision as soon as possible and no later than five days from the date of your receipt of this letter.
Thank you for your immediate attention to this matter.
cc: [Possible individuals and/or groups to whom you can consider sending a copy of your letter:]
[Health Plan Medical Director]
[Medical Group Medical Director]
[Your primary care physician]
[Your employer or insurance broker]
[Your state regulatory agency]
[State legislator who oversees insurance]
Attachments: [Material and documentation you can consider attaching:]
Copy of letter from doctor (supporting the need for the test, procedure, drug, device, and supporting need for expedited review, if applicable)
Copies of medical literature and/or letters from other doctors