Medical Appeal Letter

Before composing a medical appeal letter to convince officials at your insurance company to pay for a procedure, it is important that you read your policy to make sure the procedure in question is not excluded from your coverage package. A case manager at the medical facility or physician’s practice where the procedure may be performed can help you compile the information needed to support an appeal.

Format and Content

Your insurance policy number, group number, specific claim number and any other identifying information available should be included in your medical appeal letter format. Include a brief history of your illness and the treatment you believe you need. Note the reason that has been given for the insurance company’s refusal to cover the procedure that you need. Explain why you believe the insurance company is wrong in its assessment and include any supporting documentation that may help get the decision changed. Finally state exactly what you would like the insurance company to do.

Sample

This individual’s child was born profoundly deaf and a doctor has recommended cochlear implants; however, the insurance company has refused to pay for the implants unless hearing aids are tried first. This medical appeal letter sample is written for the purpose of stressing to the insurance company that the doctor has determined, based on the child’s specific condition, that hearing aids would be a waste of time, a source of unnecessary discomfort for the child and a useless expenditure for the insurance company.

Dear Mr. Johnson,

I am writing to appeal ABC Insurance Company’s refusal to cover cochlear implants for my daughter, Brittany Baker, unless we first try a series of hearing aids. Brittany was born profoundly deaf and is missing essential parts of her ear components needed for hearing aids to work. I have attached the medical records associated with her birth, results of hearing tests that have been performed, CT scan records showing the areas where ear components are missing and a letter from her doctor stating why hearing aids would be a waste of time and money as well as a source of unnecessary discomfort for my child.

I realize that cochlear implants are expensive, but they are covered in my health insurance policy. I realize that it would be less expensive for the insurance company if hearing aids would suffice; however medically there is absolutely no way hearing aids will work for Brittany’s specific condition. You will be spending even more money if you require the hearing aids to be tried first and then end up paying for the cochlear implants anyway because the hearing aids will fail. It would cost the insurance company less money to approve and pay for the cochlear implants without going through the production of trying hearing aids first. This is what I respectfully ask you to do.

Thank you for your consideration.

Sincerely,

Carol Baker