Medical Necessity Appeal Letter

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Conflict between providers and insurance companies goes on constantly in regards to procedures and medications for patients. Sometimes a physician will use his or her expertise to determine that a particular procedure or medication is the right approach for restoring the patient to health, but insurance company officials may refuse to pay stating that the procedure or medication was too expensive, not medically necessary and that a less expensive procedure or medication would have helped the patient just as well. These types of conflicts typically result in the filing of a medical necessity appeal letter.

Content and Format

A medical necessity appeal letter format can be tricky. First check the patient’s policy to make sure the procedure is not specifically excluded. In the letter, state the provider’s name, patient’s name, date of service and procedure in question. Also list the patient’s identification, group, policy and claim numbers. Describe treatment that has already been done on the patient, the results of the treatment and the reason the newer, more expensive treatment, was administered. Close the letter by noting how the treatment in question has helped the patient.

Sample

New medications are being developed every day for specific ailments and the newest medications are usually the most expensive. This medical necessity appeal letter sample deals with a patient who received the newest type of injection for arthritis in her knee. The injection was expensive and the insurance company declined to pay for it stating that one of the less expensive injections would have sufficed. A representative from the physician’s office is appealing the insurance company’s decision based on the fact that other injections have been given to the patient in the past with no success; therefore the physician elected to try the new medicine which is not an exclusion in the patient’s insurance contract.