Prior Authorization Appeal Letter (Template & Guide)

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[Your Full Name]
[Your Phone Number]
[Your Email Address]

March 25, 2026

[Insurance Company Name]
Prior Authorization Appeals Department
[Insurance Company Mailing Address]

Re: Appeal of Prior Authorization Denial
Member ID: [Your Member ID]
Reference/Authorization Number: [Reference or Auth Number]
Treating Provider: [Doctor/Provider Name]
Procedure/Treatment: [Procedure/Treatment Name]
Date of Denial: [Date of Denial]

Dear Prior Authorization Review Team,

I am writing to formally appeal the denial of prior authorization for [procedure/treatment name], as indicated in the denial notice dated [denial date]. I respectfully request reconsideration of this decision based on the medical evidence and clinical necessity outlined below.

CLINICAL NECESSITY

Diagnosis: [ICD-10 code and diagnosis description]

This specific procedure is medically necessary because [explain why this treatment is needed for your condition, including symptoms, test results, and clinical findings].

If this treatment is delayed or denied, the following medical consequences are likely: deterioration of my condition, increased risk of complications, prolonged suffering, and the potential need for more invasive and costly interventions in the future.

TREATING PHYSICIAN'S RECOMMENDATION

My treating physician, Dr. [Doctor Name] ([Doctor Phone Number]), has determined that this procedure is the appropriate standard of care for my condition. Their clinical rationale is as follows:

[Doctor's clinical rationale for why this treatment is medically necessary, including relevant test results, failed conservative treatments, and clinical guidelines supporting this approach]

PREVIOUS TREATMENTS / ALTERNATIVES EXHAUSTED

[Describe conservative or alternative treatments that have been tried and failed, or explain why alternative treatments are not clinically appropriate for your specific condition. Include dates, durations, and outcomes of previous treatments.]

SUPPORTING DOCUMENTATION

I am enclosing the following documents to support this appeal:
- Letter of medical necessity from my treating physician, Dr. [Doctor Name]
- Relevant medical records and test results
- Clinical notes documenting the severity of my condition
- Treatment history and prior interventions
- Peer-reviewed clinical guidelines supporting this treatment

REQUEST FOR PEER-TO-PEER REVIEW

I request that my treating physician, Dr. [Doctor Name] at [Doctor Phone Number], be given the opportunity for a peer-to-peer discussion with your medical director before a final decision is made. A direct clinical conversation is often the most effective way to clarify medical necessity and resolve authorization disputes.

REQUESTED ACTIONS

Based on the evidence provided, I respectfully request that you:

1. Approve the prior authorization for [procedure/treatment name] as medically necessary
2. If unable to approve, arrange a peer-to-peer review between my treating physician and your medical director
3. Provide a written explanation with the specific clinical criteria that were not met, including the clinical policy or guideline used in your determination
4. Provide instructions for requesting an external independent review if this appeal is denied

Please respond within the timelines required by applicable law (typically 30 calendar days for standard appeals, or 72 hours for urgent/expedited appeals). If this appeal is denied, please treat this letter as my formal request for information on how to initiate an independent external review.

Thank you for your prompt attention to this matter. I look forward to a fair reconsideration of this medically necessary treatment.

Sincerely,

[Signature]
[Your Full Name]

Enclosures:
- Copy of prior authorization denial letter
- Letter of medical necessity from treating physician
- Relevant medical records and test results
- Clinical notes and treatment history
- Peer-reviewed guidelines and clinical literature