Health Insurance: Claims: Appeals: Sample Letter: Not Medically Necessary
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.
You will notice there is reference in the letter to both state mandated coverage and to a regulatory agency.
- If you don't know the law of your state or the regulatory agency, go 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 Department of Insurance. They can guide you. To locate contact information for your state insurance department, see: www.naic.org . Click on "NAIC States and Jurisdictions."
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.
The sample letter
[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.
[If you are in a state that has "mandated benefits laws," or laws that require plans to provide certain coverage, it can be helpful to refer to provisions that require coverage for the treatment or service you are seeking. The section above tells how to find out if your state has such a provision. 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.
(Name of insurer or medical group) should authorize me to seek (undergo this procedure, start treatment, obtain the medical device) right away. 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.
Attached is documentation of my medical condition and information supporting the medical necessity for my request. Please let me know if you need adidtional information.
Please 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)
To Learn More
More InformationAppealing Denial Of A Referral Or Pre-certification For Treatment
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