Insurance Appeal Template

Insurance Appeal Template | PatientLead Health

Instructions

Replace the bracketed sections with your information. Attach supporting documentation such as medical records, imaging reports, and provider notes. Keep tone factual and professional.

[Your Name]
[Address]
[City, State ZIP]
[Insurance Company Name]
[Claims Department Address]
[Date]

Subject: Appeal of Denied Claim [Claim Number] – [Procedure/Medication Name]

Dear [Insurance Medical Director or Appeals Department],

I am submitting this appeal regarding the denial of coverage for [procedure/medication/referral] on [date of denial]. My provider, [Provider Name], has determined that this treatment is medically necessary for the management of my diagnosed condition, [Diagnosis Code and Name].

The denial cites [insert reason from denial letter]. However, current clinical guidelines and my medical history support the necessity of this request. [Briefly describe relevant medical history, failed treatments, or supporting evidence.]

This request meets medical-necessity criteria based on current standards of care and published evidence. I respectfully request that this decision be reconsidered.

Thank you for your time and attention to this matter.

Sincerely,
[Your Signature]
[Your Contact Information]

Insurance Appeal Letter Template

Instructions