Appeal Letter: "Not Medically Necessary" Denial (Template & Steps)

Your Letter:

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

September 26, 2025

[Insurance Company Name]
Appeals Department
[Insurance Company Address]

Re: Appeal of "Not Medically Necessary" Denial
Plan Type: [HMO/PPO/ERISA]
Member ID: [Your Member ID]
Claim Number: [Claim Number]
Date of Service: [Date of Service]
Provider: [Provider/Hospital Name]
Date of Denial: [Date of Denial Letter]

Dear Appeals Review Team,

I am writing to formally appeal your denial of coverage for [procedure/treatment name] performed on [date of service]. Your denial letter dated [denial date] stated the service was "not medically necessary." I respectfully request reconsideration based on the medical evidence provided below.

MEDICAL NECESSITY

My treating physician, Dr. [Doctor Name], determined this treatment was medically necessary based on:

1. Diagnosis: [Primary diagnosis and ICD-10 code]
2. Clinical presentation: [Describe symptoms, test results, and clinical findings that necessitated the treatment]
3. Treatment rationale: This procedure was the appropriate standard of care because [explain why this specific treatment was needed and why alternatives were not suitable]

The treatment was:
• Consistent with accepted medical practice standards
• Clinically appropriate for my diagnosis and symptoms
• Not primarily for convenience
• The most appropriate level of service that could safely be provided

SUPPORTING DOCUMENTATION

I am including the following supporting documents:
□ Letter of medical necessity from Dr. [Doctor Name] (attached)
□ Relevant medical records and test results
□ Clinical notes documenting the severity of my condition
□ Peer-reviewed medical literature supporting this treatment
□ [Insurer policy/guideline citation, if known]

REQUESTED RECORDS & CRITERIA (PLEASE PROVIDE)

To ensure a fair review, please include in the appeal record and provide to me:
• The complete clinical policy/criteria used to deny this claim (and the specific criteria I allegedly did not meet)
• Names/credentials/specialty of reviewers and any utilization review notes
• All codes used in adjudication (ICD-10, CPT/HCPCS, modifiers) and any claim edits applied
• Instructions and contact details for a physician-to-physician (peer-to-peer) discussion, if available

COVERAGE PROVISIONS

This treatment should be covered under my plan because:
• It meets the definition of "medically necessary" as outlined in my policy
• Similar treatments have been covered for comparable diagnoses
• The procedure is not listed as an exclusion in my benefits summary

REQUEST FOR RECONSIDERATION

Based on the medical evidence and my physician's clinical judgment, I request that you:
1. Reverse the denial and approve coverage for this medically necessary treatment
2. Process payment for the claim according to my benefit provisions
3. Provide written confirmation of approval

I am available for a peer-to-peer review between your medical director and Dr. [Doctor Name] if helpful.

Please respond within the timelines required by my plan and applicable law (often 30 calendar days for standard appeals and 72 hours for urgent care). If a different deadline applies, please provide the applicable timeframe in writing.

If this appeal is denied, please treat this letter as my request for instructions to initiate an independent external review where available and provide the required forms and deadlines.

Thank you for your prompt reconsideration of this matter.

Sincerely,

[Signature]
[Your Name]

Enclosures:
• Copy of original denial letter
• Letter of medical necessity from physician
• Medical records
• Test results
• Supporting medical literature